Henry Vincent Keogh Petition (continued)

Particulars – the Infant Deaths inquiry

In 1993-1994 serious concerns had been raised by members of the medical profession regarding a number of infant deaths. Dr Manock’s autopsy reports had determined that each of the children had died from bronchopneumonia. The doctors were concerned that each of the infants had sustained serious physical and non-accidental injuries. An Inquest into those deaths was conducted under Section 12 of the Coroners Act. The hearings took place on various dates between August 1994 and August 1995. They concerned the following children:

Storm Deane who died on 16 October 1992 at the Adelaide Children’s Hospital.

William Barnard who died on 31 July 1993 at the Adelaide Children’s Hospital.

Joshua Nottle who died on 17 August 1993 at The Modbury Hospital, Adelaide.

In each case, the cause of death was given by Dr Manock as bronchopneumonia, associated with other features.

Serious concerns were expressed to the Coroner by police investigators who were involved in the coronial investigation and CIB areas. Eminent medical practitioners, who are experts in paediatric medicine, and non-accidental injury to children, also expressed concerns that the postulated cause of death may not be correct. The concern of all these people was that the diagnosis might have masked serious child abuse or even homicide.

The Coroner decided to conduct an inquest. He took the view that all 3 cases were similar, and may have indicated a systemic deficiency in the way child abuse is investigated in this State. He said that he was very concerned to ensure that the issues relating to one inquest did not contaminate the others.

Dr Tony Thomas, Associate Professor in Anatomical Pathology, at Flinders Medical Centre, prepared a lengthy report for the Coroner on all matters of pathology related to these 3 deaths. He stated that there were many areas where histopathology and weighing of organs was not done.

Storm Deane

Dr Terry Donald (Director of Child Protection at the Royal Adelaide Hospital) said that the chest injuries looked as if an adult hand had been squeezing the chest. In his view, they resulted from “serious physical abuse”, on at least 2 occasions prior to death. Dr Byard, a pathologist, suggested that there should have been histopathological examination:

Of the buttock lesion which Dr Manock did and concluded from this that it was not a burn. 

Of the rib and skull fractures which were not done by Dr Manock. 

Of the brain which was not done by Dr Manock before he expressed his opinion. It was later done by Dr Blumbergs.

Of the eyes which was not done by Dr Manock.

Dr Thomas stated that the body itself was not weighed or measured. Some of these practices were described by him as “time honoured”. Dr Thomas agreed that the injuries were not related to birth trauma, but were non-accidental. In Dr Thomas’s view, histology of these areas was “essential”.

Dr Manock was the Director of Forensic Pathology and had been engaged in that capacity in South Australia, since 1968. The Coroner took the view that Dr Manock’s understanding of the criminal process, and his obligation to provide lines of inquiry to investigators, would be second nature to him. Dr Manock acknowledged that the height and weight of the baby, and the weight of lungs, would have been “helpful”.

Dr Thomas said that bronchopneumonia was not the cause of death and that the most likely cause was “non-accidental”. Having acknowledged the scenario outlined by counsel assisting the Coroner relating to non-accidental injuries, the Coroner said that “it is extraordinary” that Dr Manock did not conduct further inquiries to exclude that possibility. Dr Manock explained that:

“it was important that the pathologist should be careful not to influence the investigation and suggest suspicion which is unwarranted.”

Dr Manock said that he was surprised that further investigations were not followed up by the police. Detective Frick, in turn, said that he was “outraged” by that suggestion.

The Coroner stated that:

“..the post mortem examination achieved the opposite of what should have been its purpose – it closed off lines of investigation rather than opening them up.”

The Coroner determined that the cause of death should be recorded as “undetermined”. It was his view that proper examination of the issues had not occurred in this case.

William Barnard

Dr Thomas evaluated the pathology evidence in this case. He said that there was no evidence of the weight of the body organs. He said that lung weights would have been invaluable. He said that there was no temperature of the body which was “time honoured practice”. There was no block-key to identify the origin of tissues which had been taken for examination. The absence of this made interpretation of those tissue samples difficult.

Dr Manock said he could not recall why he did not weigh the lungs. He now agrees that bronchopneumonia was unlikely to have been the cause of death. He was unable to recall what he saw in the slide to lead to this conclusion. Dr Manock says he did not send the brain off for examination, because he was waiting for something from the detectives, so that he could tell the specialist what to look for.

The Coroner said:

“As Coroner I am perplexed at this statement. Dr Blumbergs is perfectly capable of examining the brain without being told what to look for...”

“I am quite unable to accept Dr Manock’s explanation as to why he did not offer this further information to the investigators immediately after the post-mortem examination concluded. It is spurious, in my opinion, to suggest that he did not offer these alternative explanations because he was waiting for further information from the detectives. Unlike Dr Blumbergs, who did not need to be told what to look for, the detectives should have received all the assistance possible so that their investigations could focus on particular issues. With a diagnosis of bronchopneumonia the investigation had no focus.”

The Coroner took the view that Dr Manock’s conclusion caused the death to be written off as a “natural” death, and its investigation was basically cut off before it began. He concluded, as he had done in the previous case, that the autopsy achieved the opposite of its proper purpose. It “closed off” lines of investigation, rather than opening them up. The Coroner said that the lack of a thorough investigation was disturbing, particularly as this was the second such death in this family, in strikingly similar circumstances.

Joshua Nottle

Dr Donald advised the police that the rib fractures were done by squeezing by an adult. He took the view that the spine fracture was most likely to be non-accidental, and not as a result of resuscitation. He was of the view that the lung weights did not support the view of bronchopneumonia. He was “mystified” by Dr Manock’s suggestion of bronchospasm which is a physiological process and undetectable after death. He agreed with Dr Thomas, with regard to the inadequacy of the autopsy.

Dr Donald said that he considered that there had been severe shaking and throwing of the child. He disagreed that the spinal injury could have been caused by resuscitation.

Dr Thomas’s report showed that no height or body weights were given. It also appeared that there had been no histological examination of the bruises. Organs, including the brain, were not weighed. Only the lungs were weighed. The rib fractures were noted. The fractures of the clavicles which were easily detected on the X-rays were not noted. Dr Thomas took the view that a full skeletal survey was “essential”. He also took the view that further dissection and histological examination would also have been essential. It was Dr Thomas’s opinion that further dissection and exploration of the spinal fracture would have been “mandatory”.

Contrary to Dr Manock’s view, Dr Thomas thought that bronchopneumonia was not the likely cause of death. Dr Thomas said that histological examination of the eyes should have been done, and that the brain should have been examined. He said that the “time honoured practice of taking the temperature” was not done. There was no block-key in relation to the tissues which were taken, making histological interpretation of those sections extremely difficult. 

Dr Manock said that the baby was weighed, but that the weight had been misplaced. Dr Manock said that he expected more information from the police. However, the Coroner said that he was quite unable to understand how the police could be expected to provide that information without suggestions to help them from Dr Manock. The suggestion from Dr Manock was that this became an issue between himself and the police of “professional credibility”. However, as the Coroner said, if he had done as Dr Thomas suggested, it would not have been an issue at all.

Conclusions

The Coroner concluded that, of the three deaths, that of Joshua was the most serious, with non-accidental injuries most evident. He said that Dr Manock’s diagnosis prevented the establishment of a causative link between the non-accidental injuries and the death. In the Coroner’s view, what should have been a homicide investigation became one only of serious assault. He said that:

“Dr Manock’s investigation, and his subsequent report, provided innocent explanations for the most serious injuries found on Joshua’s body, explanations that I am now satisfied were incorrect. In those circumstances, and in common with the other two cases, the post-mortem examination basically achieved the opposite of its proper purpose in that it closed off lines of investigation rather than opening them up.”

“I consider Dr Manock’s explanation that he was waiting for further information from the police to be spurious. In my view, it was incumbent upon him to provide the detectives with information so that they would know what to look for.”

The Coroner said that he had no hesitation in accepting Dr Thomas’s opinion that there was no evidence that Joshua was suffering from bronchopneumonia to any degree sufficient to cause death. The cause of his very serious physical injuries remains undetermined. The Coroner took the view that the uncertainties that now surround his death are most disturbing, but although there are grounds for grave suspicion, nothing can be proved on the basis of the evidence as it now stands.

Dr Thomas says that he sees little value in an expert opinion, which offers no clinical pathological correlation. It is his view that a full skeletal survey should be mandatory, and it was not done in any of these cases. At the autopsy, photographs should be taken of the injuries. Body and organ weights and heights should be done routinely. Temperatures should be taken. There should be histological examination of the fractures and bruises. The brain, eyes and spinal chord should be examined macroscopically and microscopically too. The Coroner said that he agreed with Dr Thomas in all that he said.

He noted that Professor Cordner said that the role of the forensic autopsy is to describe the pathological processes at death. To contribute to the reconstruction of the circumstances of the death and to put other pathologists in the same position as the one doing the autopsy. He said that it was important to record both the positive and negative findings.

The Coroner concluded that the post-mortem examinations of Dr Manock fell a long way short of achieving these aims. He said that he was “very concerned” that serious crimes may have gone unpunished as a result.

Particulars – Concerns regarding Dr Manock’s previous cases

R v Van Beelen 1972

Dr Manock said that Deborah (aged 15) had been murdered and then raped. Her body was found on Taperoo beach early in the morning.

Dr Manock gave evidence to say that it was “virtually certain” that Deborah was dead by 4.30pm, and most probably around 4.15pm. His calculation was based on the rate at which a stomach is emptied of its contents. Generally, pathologists take the view that there are so many variables involved in making such as assessment, that it would be inappropriate to use calculations of the rate of which the stomach is emptied of its contents as a factual matter capable of proof in a forensic process.

When she was found, Deborah’s radio was lying nearby. When it was retrieved, it appeared that it had been left switched “on”, and that the batteries had run down. When they were replaced, the radio immediately worked. This was curious, because the position of Deborah’s body and the radio, on the beach, was below the high-water mark. This would have meant that, according to Dr Manock’s evidence, that the tide would have come in and covered her body and the radio, during the course of the night. If that was not the case, then Deborah’s body (and / or radio) had been placed on the beach after the last high tide, which occurred at around 8pm that night. This would have been long after Mr Van Beelen had been near the beach that day.

Dr Manock’s work in relation to “diatom” testing in this case also requires re-examination. Diatoms are microscopic calcified particles, which are found in water. If it is suspected that someone has drowned, tissues can be tested to see if the diatoms in them are of a similar shape to those in the water in which the person has been found. In a number of cases where drowning has been involved, Dr Manock says that he tested the lung tissue for the presence of diatoms. Pathologists have expressed the view that this test is inappropriate, and that one should more appropriately examine the kidneys and bone marrow for the presence of diatoms.

Dr Manock was criticised for failing to take temperatures of the deceased when he first arrived at the scene in this case. We will note that there are a number of other cases where temperatures have not been taken – Keogh, Warren, Highfold, Akritidis and the Infant Deaths cases, for example. It becomes clear, in the course of the later report on this case by Mr Mullighan QC (as he then was) that the evidence of Dr Manock was still seen to be important as part of the prosecution case, at that time.

Douglas Rendell 1979

On 30 July 1979 Mr Rendell’s de facto wife Yvonne, 20 years his junior was shot dead at their home in Broken Hill. Mr Rendell claimed that the gun had gone off accidentally during a row, when it was dropped on the floor. He was charged with murder and convicted and sentenced to life imprisonment in March 1980. The evidence had been largely circumstantial. An application was made in 1985 for a judicial review of his case, but it was unsuccessful. Justice David Hunt of the NSW Supreme Court later reviewed the file and expressed some concerns about it in his findings in December 1987. Rendell was released on licence in 1988. In February of that year Sir Laurence Street asked magistrate Arthur Riedel to conduct an inquiry.

Dr Manock’s evidence in relation to whether fingerprints would be left on a gun which had been used was not accepted by the investigating magistrate:

“On the absence of fingerprints, Riedel referred to the evidence of the highly qualified Dr Colin Henry Manock, Director of Forensic Pathology in South Australia . Manock said he did not think it significant that there were no fingerprints on the rifle. Rifles, he said, were not particularly good for fingerprints. The woodwork had often been deliberately roughened to give better grip. ‘There were occasions’, Dr Manock said, ‘when no fingerprints had been found on rifles, even though it was known they had been recently used’.”
”Riedel was not quite so ready to go along with this. There were smooth surfaces, and yes, there was no reason to presume a rifle was different from any other object.”

Dr Manock gave further detailed evidence about the pattern of blood splashes. It was said that Dr Edward Brian La Brooy, who was also described as being highly qualified and a Fellow of the College of Pathologists, also supported Dr Manock. As it was Dr Manock’s evidence in this case was used to overturn the conviction.

“Two highly qualified experts [Manock and La Brooy] have furnished an hypothesis as to how the deceased may have met her death. That hypothesis accounts for most if not all of the observed factors and is consistent with accidental discharge.”

The important aspect of this account is that it was stated that Dr Manock was “highly qualified”. That factor certainly appeared to influence magistrate Riedel in his report to Justice Hunt of 9 June 1989, just quoted.
[The information in this section is taken from Justice and Nightmares – Successes and Failures of Forensic Science – Malcolm Brown and Paul Wilson, New South Wales University Press, pp 114-116]

David Szach 1980

Mr David Szach was convicted of the murder of the lawyer Derrance Stevenson whose body was found with a gunshot wound to the head, in a freezer at his home in Greenhill Road, Adelaide. Mr Szach had been intimately involved with Mr Stevenson.

Dr Manock said that Mr Stevenson had post-mortem lividity along his back. Mr Stevenson was said by Dr Manock to be wearing a shirt. It follows that Dr Manock could not have seen the lividity as he reported that he did.

It is clear that Dr Manock’s speculations about the time of death in this case were entirely without scientific validity. Dr Manock had taken a formula for determining the time of death in relation to a frozen body as a result of experiments which had been carried out and reported in the scientific literature. The experiments which had been undertaken had been conducted on a body frozen in the prone position. Therefore, Dr Manock had no scientific basis for extrapolating from the equation derived in those circumstances, and applying it to the case of Mr Stevenson for the following reasons:

The variables used in Dr Manock’s equation were clearly not known.

There was no scientific basis for Dr Manock to substitute liver temperature for rectal temperature, in the way in which he had done here.

The authors of the formula clearly did not attempt to represent that it could be used in circumstances which could be regarded as “not normal”, which was clearly the case here.

The formula had no universality, and the authors made it clear that any marked change in environmental circumstances would invalidate any of the conclusions drawn. There is no doubt here that the environment within the freezer varied considerably between the initial placement of the body and its discovery.

Fundamental to the reliability of any formulae is the accuracy of the individual factors of which it is comprised. None, apart from the liver value obtained by Dr Manock was known with any degree of comfortable certainty.

The running temperature of the freezer, at the time when the body was placed in the freezer, was unknown. In “normal” mode it would have been minus 20, but in “superchill” mode it would have been minus 28. A significant difference.

The core body temperature at the time of death was assumed by Dr Manock to be 37 degrees, but this was unjustified, and he had no evidence to support this.

Dr Manock had no scientific evidence upon which to base his hypothesis that the time periods involved would be lengthened by 40% due to the foetal position of the body in the freezer. The original experiments were conducted on bodies in the prone position, so Dr Manock needed to “adjust the formula” without having any scientific basis for doing so.

Dr Manock had no way of determining the time interval between the shooting and the placement of the body in the freezer. Reliance on the fluidity of blood in the major vessels, or of the blanching of the post-mortem lividity, was totally unacceptable. The timing of the onset of this latter post-mortem feature is so variable as to be totally unreliable in its use for any scientific purpose.

It is clear that Dr Manock appeared to have succumbed to the very real temptation of furnishing police with a piece of evidence, which cannot in reality be provided.

Mrs Emily Perry 1982

Mrs Emily Perry was charged with attempting to murder Mr Perry, her third husband. The prosecution alleged that she had administered poison to him with the intention of killing him. She was convicted on both counts. It was also alleged that she had poisoned her previous husband, her brother and her previous de-facto partner. Mrs Perry was convicted of the offences charged, and her appeal to the Court of Criminal Appeal was unsuccessful.

In her successful appeal to the High Court of Australia, there were extensive criticisms of the forensic evidence and of the prosecution. Murphy J said of Dr Manock’s evidence:

“28. Mr Perry had a history of motor bike accidents, including severe injury to Mr Perry’s facial structure and nasal passages which led to symptoms such as rhinitis. The prosecution's expert witness attributed this to arsenic or lead poisoning [by Mrs Perry] - although the condition had existed years before Mr. Perry made Mrs. Perry's acquaintance and had been the subject of a published medical article on facial reconstruction.”
[(1982) 150 CLR p599.]

“29. Forensic Evidence. The evidence particularly in relation to Duncan, but also of the other alleged poisonings including that of Mr. Perry, reveals an appalling departure from acceptable standards of forensic science in the investigation of this case and in the evidence presented on behalf of the prosecution.”
[(1982) 150 CLR 580 emphasis added]

Murphy J said:

“29.The prosecution’s evidence fell far short of this ideal. If the expert assistance available to the prosecution in this case is typical, then the interests of justice demand an improvement in investigation and interpretation of data and presentation to the court by witnesses who are substantially and not merely nominally experts in the subject which calls for expertise.”
[(1982) 150 CLR p600, emphasis added]

Dr Manock had raised the Smith case (the ‘Brides in the Bath’ case), in the Perry trial, just as he was to do again later in Mr Keogh’s case.
[R v Smith (1915) 11 Cr. App. R. 229]

The High Court judges in Perry determined that it was inappropriate for Dr Manock to have raised the Smith case in Perry as he had done. The issues in the two cases, they said, were quite distinct. Mr Keogh takes the view that is was equally inappropriate of Dr Manock to have raised the Smith case in the circumstances of the case in which Mr Keogh found himself. 

Mrs Lorraine Moss 1986

Dr Manock told the Melbourne Coroner’s Court that Leonard John Moss’s death was not suicide or accident. Lorraine Moss, his wife, was charged with his murder. Mr Moss had used lead arsenic to spray his fruit trees. Dr Manock said that his death was due to deliberate poisoning.

Dr Manock took the view that as Mr Moss had ingested the poison on several occasions that would be inconsistent with a suicidal administration. Dr Manock said that accidental poisoning does not result in multiple ingestion. As a result, Dr Manock stated that Mr Moss must have been deliberately poisoned. The reasoning here is clearly faulty. Whether something is accidental or deliberate depends upon a person’s knowledge and intention at the time, and has nothing whatever to do with whether the act is a single act or a series of acts.

Dr Manock said that arsenic was easy to administer as it had no taste or smell and no texture if put into food in small quantities.
[21 August 1986 – Advertiser – “Man given arsenic over period”]

It is exactly because of these qualities that there could have been an increased likelihood of accidental ingestion.

In a newspaper article published five years later, Dr Manock made this very point. Dr Manock was discussing the way in which US pathologists ruled out the murder of a president – Zachary Taylor - who died in 1850. According to Dr Manock the discovery of arsenic in the exhumed body would have been far from conclusive. In those days, he said, arsenic was quite ubiquitous. It was used in cosmetics, nit powders, wallpaper and weedkillers.

Dr Manock then stated that:

“If the President had been a keen gardener, his body may well have shown the presence of arsenic.”
[4 July 1991 – The News – “Science of things to come”]

This is the very point which Dr Manock had contradicted in the Moss case, where he said that gardening (the spraying of fruit trees) could NOT lead to accidental ingestion.

Wendy Cooke 1984

The date of the autopsy in this case was 14 April 1984. In Dr Manock’s statement, he said he went to the Bolivar Treatment works at about 1330 hours. He was shown to a parked car, on the front seat of which was the body of a woman with extensive putrefaction. The body was naked, except for a pair of jeans, which were around her ankle. He did an autopsy at 1500hrs. He said that there were no flies in the car, so the car must have been closed. In his opinion, the death was around the evening of 12 April 1984 , with death an hour or so after the last meal. There was a gas cylinder in the back of the car with the tap in the “on” position. Dr Manock said that “I did not consider testing to be of value.” It is not clear what he meant by this.

In a report from Dr Plueckhahn, Professor and Director of Pathology, Consultant Forensic Pathologist, Victoria, it was stated that the autopsy report from Dr Manock was not detailed, and was often subjective rather than objective. Dr Plueckhahn said that he did not agree with Dr Manock’s anatomical diagnosis of “strangulation by ligature” or with various other of his views. He said that the positive and negative findings which Dr Manock recorded were NOT typical of those of an asphyxial death due to mechanical obstruction of respiration. He went on to refer to a number of technical issues in Dr Manock’s report, and said that some of the bruising which Dr Manock referred to may have occurred before death, but that it was NOT necessarily ante-mortem. He said that there was some evidence in the photographs to suggest that it was “more likely” that the bruising was occasioned after death. Dr Plueckhahn said that the various statements made by Dr Manock in his report were either “not tenable” or that they had “little scientific basis”. He said that there was little convincing evidence in the photographs that the majority of the “so-called” bruising as described by Dr Manock was ante-mortem in nature.

The case is particularly important to the consideration of Mr Keogh’s trial. Dr Manock asserted that the bruising found on the body of Ms Cheney was ante-mortem, and had occurred within a short time of her death. It is important to note here that Professor Plueckhahn is observing that Dr Manock’s interpretations of observable features and as to whether they are ante-mortem or post-mortem are not reliable.

Dr George Duncan 1986

Dr Duncan was a law lecturer at the law school at Adelaide University. He was a known homosexual, and had been found dead in the River Torrens, which runs along behind the University. The grass areas on the banks of the Torrens, behind the university, were a known homosexual meeting area.

Dr Manock said that Dr Duncan had probably been gripped by the upper arms before he went into the river. He said that Duncan had probably drowned very quickly and with little struggling. It appeared, he said, that “he had hit a rough surface, knocking the wind out of him before he drowned”. This could be nothing more than mere speculation. Dr Manock could have had no observable basis at autopsy for making such a claim. This is again, Dr Manock confusing his role as a scientific person, with that of an investigator, which the Splatt Royal Commission determined to be unacceptable. Dr Manock’s job, as a pathologist, is to record the known and observable features at autopsy, and to help the court to make sensible inferences from those observations.

Dr Manock said that no injury had been found which would have contributed to Dr Duncan’s drowning.

The Minutes of the South Australian Premier’s Department, dealing with this matter, state that in relation to this file, there is to be “no access for fifty years”. It also notes that the report is incomplete, and that certain parts were apparently removed by the Chief Secretary prior to 5 August 1985. The South Australian Government has recently released the Report by Detective Chief Superintendent RW McGowan of New Scotland Yard into the death of Dr Duncan.

Elefteros Akritidis 1987

The body of “Terry” Akritidis was found at the base of a police radio communication tower late on the evening of 3 August 1987, by police officers who happened to attend at this remote location late in that day.

No photographs were taken when his body was found. The police reported that their camera had not been working, so they said that they were unable to take photographs. Dr Manock gave evidence at the inquest in place of a Dr Ashby whose whereabouts at that time were said to be “unknown”.

Dr Manock later said in evidence that he thought that the word “discovery” in the autopsy report was probably wrong. Dr Ashby had probably meant that the death had occurred 12 hours before the body had been undressed at the autopsy. 12 hours before the autopsy was some 2 hours after the body had been discovered.

It is clear that Dr Manock was unaware of the height of the tower when he was giving his evidence. He said at the inquest:

“I wish I knew what the height was – 140feet, 200 feet or 400 feet.”

The Coroner then pointed out to Dr Manock that the tower was no more than 150 feet high, therefore Mr Akritidis could not have fallen a greater distance than that. Dr Manock then stated that he would not expect to see external injuries where a person had fallen 150 feet and landed on concrete, because:

“the clothing would be interposed between the skin and the surface which it strikes.”

When asked if he had read a body of material on the topic of bodies falling from a height, Dr Manock stated that he had. When questioned further about the nature of this “reading”, Dr Manock said that he had in fact read “his own previous autopsy reports”.

Dr Manock stated that where the blood pressure in the peripheral tissues drops very rapidly indeed, there is unlikely to be external bleeding as there is no effective blood pressure to cause such bleeding. Dr Manock said:

“When the aorta is torn there would be no bleeding. The blood pressure disappears almost instantly.”

This is incorrect. 

Dr Manock stated that in 1987, it would NOT have been usual to take photographs at an autopsy. He said:

“This [the autopsy] was started at 8.15 and our photographer arrived at 8.30.”

It remains unclear what work the photographer would have been engaged in if it was not part of his duties to take photographs of autopsies. 

Dr Manock said that without temperatures being taken, death could have occurred:

“12, 24, 36 hours a week, something of that sort [presumably prior to the body being found.”

In fact, Terry was at the local police station some 12 hours before his body was found. Clearly it would not have been possible for him to have been dead for:

“... a week, something of that sort.”

Dr Manock stated that hypostasis here would be non-existent:

“because of the torn aorta or rigor mortis.”

Neither of these things would have the effect of preventing hypostasis from occurring, although the former may have had some effect upon the extent of it.

Dr Manock said that in all cases other than those where there is police suspicion that a homicide might have been carried out, the body would be brought to the mortuary and an autopsy carried out the next morning. This is clearly a deficient procedure. It is the role of the autopsy to help determine if there are suspicious circumstances. Before the autopsy is concluded, it would be inappropriate of police officers or anyone else to make any determination as to whether or not the death is “suspicious”.

Dr Manock said that it was “not usual” for him to fill in a body chart, as this was a matter of choice. He said that he preferred to “write descriptions” as he had not any “artistic ability”. It is clear that the utilisation of a body chart by a pathologist, does not require the pathologist to have any artistic ability, as Dr Manock suggested. A body chart is an essential component of the proper documentation of autopsy procedures. Dr Manock’s purported explanation in this regard is seriously deficient.

John Highfold 1988

Mr Highfold was aged 30, and was an Aboriginal man who was found dead in custody. Mr Highfold was known to be epileptic, and was being treated by medication. Dr Manock determined that Mr Highfold had died as a result of an epileptic seizure. At the hearing of the inquiry into Aboriginal Deaths in Custody, a Professor (a specialist on epilepsy) said that there was no test, which could establish epilepsy as the cause of death. He said it was “circumstantial” to conclude that Mr Highfold had died from a seizure.

The Professor continued to say that all of the major organs should have been examined and the blood tested for drugs, especially Dilantin, which was being used to treat Mr Highfold’s epilepsy. Dr Manock, he said, did not do that.

A Doctor  said that Mr Highfold’s medical file “appeared to have been lost”. It could not be found and there was no record of it being passed to the Coroner. Mr Highfold’s clothing had also “gone missing”, and it was therefore not able to be examined.

Dr Manock told the Commission that “cost” had been a factor in deciding not to undertake the blood tests. He said that full toxicological testing could have cost $2,000. Dr Manock said that he did not do so as “Highfold did not have access to poison”. It is clear that Dr Manock could not have known what Mr Highfold did and did not have access to.

Dr Manock also said that because Mr Highfold’s stomach was empty, a drug overdose was unlikely. There are, of course, many mechanisms by which drugs can get into a person’s system. Absorption through the stomach is only one of them.

Dr Manock produced slides from his pocket in an attempt to show that he had examined more than the brain. One has to say that whilst such a gesture might be stimulating for its rhetorical effect, it is not sound procedure. Clearly nobody present at the hearing would know whether the bits of glass being waved around were actually slides, and if they were, what information the slides might contain.

Mr Eames (counsel assisting and now “Justice” of the Victorian Supreme Court) said to Dr Manock, that where a person is found in a cell with no apparent cause of death, would you not agree that a heavy responsibility is placed on the pathologist to examine and exclude all possibilities? Dr Manock said – “No I would not”.

Mr Eames asked if it would be a failure by a pathologist not to gain access to the full medical records of a prisoner who had died in custody. Dr Manock said “Yes”.

The finding in this case was based on assumptions which have not been satisfactorily proven.

No photographs were taken of Mr Highfold’s cell. Clothing was not preserved and a torn collar attracted no suspicion.

When Justice Muirhead released his findings, he was critical of both Dr Manock, and the Coroner Mr Ahern.

Gerald Warren 1991

In this case, two men were convicted for the killing of a young Aboriginal boy, Gerald Warren, aged 15, who was found dead on a dirt track outside Port Augusta.

Dr Manock said that if the boy had been beaten with a metal pipe, or if he had had corduroy pressed against his skin, he would be left with the same injuries. This is clearly absurd.

He then went on to say that if the boy had fallen out of a car, or if the car had been driven over the top of him, the resulting injuries would also have been the same. Again, this is equally absurd.

Later in the same case, Dr Manock had stated that he estimated the time of death according to the extent of blow-fly activity. He later told the court that he had “misunderstood” the nature of blow-fly activity. It is disturbing that Dr Manock could make such a mistake, given that these factors are important to the determination of the timing of a death which has occurred in the open. Dr Manock is supposed to have had considerable experience of Australian conditions, and could be expected to know how blow-fly activity can be important to determining the time of death in such circumstances.

Dr Manock had also timed the death according to the amount of bird droppings which he observed at the scene. He later told the court that his observations in this regard were “just a layman’s observation” - despite the fact that he had been called as an expert witness.

Dr Manock also said that the boy’s death had occurred between noon and 4pm on the day on which he was found. When pressed about which aspects of his reasoning still supported that conclusion, he said, “I don’t think I was restricting the timing”. When he was asked why he hadn’t “widened the ambit” he said, “I didn’t put any range of possibility to any great extent”. Clearly this was false.

Dr Manock stated that there was no specific evidence with regard to the time of death. He “just felt” that the body had not been exposed for full daylight hours.

Dr Manock stated that in “normal circumstances”, the body temperature would be taken. However, in this case, “as the environmental temperature” was at the same level or higher than the body temperature, he said that there was no possibility of measuring cooling to estimate the time of death. Dr Manock has been criticised in many cases for not taking body temperatures. In the Infant Deaths cases, Dr Thomas referred to this as a “time honoured practice.” It was not done in Van Beelen. It was not done in Akritidis. It was not done in Keogh. It was not done in this case.

Dr Manock said that “the intensity of the bruising had changed around the margins”, but that he didn’t see why that should indicate anything about the time of death. In Keogh he was to observe that the darkening of bruises after death indicated that the bruises had been caused close to the time of death. He then went on to say in this case that “a change of colour” in bruising does not apply to dead bodies. His claim that there was a “darkening of bruises” after death is inconsistent with his other claim that a change of colour in bruising does not apply to dead bodies.

Dr Manock also said that, “there was nothing to indicate there had been repeated blows to the body”. We know that there were extensive injuries to the hands and face of the victim, and that there were extensive internal and external injuries. In the light of these facts, Dr Manock’s comments do not make sense.

Dr Manock then said that he agreed that “it looked as though” there was a wet area on the body in the photograph, but he could not say what it was or how it might have got there. We can only observe that on such a hot day, it could not have been there for very long. It was surely part of Dr Manock’s duties to explain all aspects of the circumstances relating to a dead body.

A schoolboy – Darwin 1999

In this case, Dr Manock determined that an English schoolboy, who had died whilst playing rugby, had died as a result of heatstroke. Dr Thomas from the Flinders Medical Centre was subsequently asked to provide a second opinion.
[5 August 1999 - report from Dr Tony Thomas]

Professor Thomas determined that the diagnosis of heatstroke was wrong, and that the boy had in fact died as the result of a heart defect. Dr Thomas said that the boy was 18 years old and on a school rugby tour. He had left England on 18 July 1999 and arrived in Australia on 23 July. The team had played in Sydney, Brisbane and Cairns. The team arrived in Darwin on 4 August, and they played a game early in the evening on 5 August. Towards the end of the game, the boy was seen to fall backwards and began to twitch. He was unconscious and was breathing in a laboured manner. Resuscitation attempts failed. Dr Thomas said, “I have absolutely no doubt whatsoever that this is a sudden unexpected natural cardiac death and that heat stroke played no part in the causation of death”.

Professor Thomas went on to make the following points in his report:

Sudden death with no previous symptomology is not that of heat stroke. It is clear that Dr Manock had misdiagnosed heatstroke. The symptoms are not the same.

Adam had not been playing long enough to develop heatstroke. It is incorrect to say that the boy came from a cold climate to the tropics. He had come from an English summer to the Australian winter, where temperatures were comparable in each of those places.

There had not been an incident of heatstroke, amongst any of the other schoolboys, and no similar event in the last 6 years.

In interpreting the heart weight, Dr Manock failed to take into account the body weight.

Dr Manock’s interpretation of “interstitial haemorrhage” within the heart was not correct.

Dr Manock said that the lungs showed signs of muscle spasm. There is absolutely no way that such a “spasm” could be detected after death. There are absolutely no signs to support such a diagnosis macroscopically or microscopically. The lungs are slightly heavy, but not twice as heavy as Dr Manock stated. This is a normal finding at autopsy.

In conclusion, Dr Thomas said that the death had nothing whatever to do with heatstroke. He also said that the information provided in the autopsy report was grossly inadequate. He said that a more comprehensive examination of the heart should have been performed.

Stephen Webster 1991

A 39 year old Aboriginal man, Stephen Webster, would probably not have died if a struggle with the police had not occurred. Martin Penhale, counsel assisting the Coroner, said that the inquest should determine if the arrest was justified or appropriate. Mr Webster had 2 artificial feet. Dr Manock said that he died of brain damage caused by heart failure. He said that the tests showed he had not been taking his medication correctly.

Dr Manock explained that Mr Webster’s resistance was probably a post-epileptic response.
[23 October 1991 – The Advertiser]

Clearly Dr Manock has demonstrated that he has little understanding of epilepsy. In this case he was using the “epilepsy” explanation to exculpate the police for responsibility in Mr Webster’s death.

Kenneth Hill 1992

The key witness in a murder trial, it was reported that Mr Hill had died from a severe haemorrhage at the base of the brain. Mr Hill had been placed in protective custody after he became the key witness in the murder of a Yatala Labour Prison inmate in 1989. Inmate James Fricker 25, had been charged with the stabbing murder of fellow prisoner Anthony Stone, in the prison’s exercise yard on 2 October. However, when Hill, the only Crown witness died, the charges were dropped.

Dr Manock said that he found no signs of external or internal violence. He told the Coroner that he believed that the cause of death was the result of “some stressful activity”, which had raised Hill’s blood pressure, which had led to the haemorrhage. Dr Manock said that he thought that the haemorrhage was the result of a developmental abnormality.
[The Advertiser – 28 August 1992]

It is clearly important to any proper analysis of the situation, to have the details of the tests, and histology which was done, to ascertain if there is any proper basis to those conclusions.

Peter John Marshall 1992

Mr Marshall was aged 35. The police went to his unit where he was found lying next to his bed with blood pooling around his head. Dr Manock attended at the scene and concluded that Mr Marshall had died by falling out of bed. The press reports said that everyone went home and the house was tidied up. Mr Marshall’s body was taken to the mortuary.

In accordance with standard practice in South Australia, “there being nothing suspicious”, nothing further was done until the following day. During the autopsy, a bullet hole was found in the side of Mr Marshall’s head, with a bullet lodged in his brain. The Forensic Science Centre said that unless a late afternoon death was suspicious the autopsy was done the next day. If a crime was suspected, they said, a pathologist would start immediately. The press reports said that the police “smarted” over the delay, the crime-scene tape was put back up, but the damage had been done.

Ms Smoker 1992

Ms Smoker died from a heart attack, after receiving a kidney. It was thought that Ms Smoker had been overdosed with potassium at the hospital, by mistake. Dr Manock said that as the potassium levels in a body always rose after death, then it would not be possible to develop any meaningful correlation between the post-mortem level and the level which may have existed before death.

Dr Manock said that high levels of potassium make the heart “more sensitive” and that if stress were applied to a heart under this condition, it could stop. Dr Manock said that as potassium levels in a body always rose within an hour of death, then it would not be possible to develop any meaningful correlation between the post-mortem level and the level, which may have existed before death. Dr Manock said that Ms Smoker’s heart was “severely diseased” and “under a considerable degree of stress”. Unfortunately, Dr Manock is not here describing the observations, which he made (if any) which would have enabled him to form such conclusions.

When Dr Manock said that Ms Smoker’s heart should have weighed about 300 grams, but it actually weighed some 500 grams, we have to bear in mind that in the Carter case Dr Manock failed to correlate heart weight with body mass. When Dr Manock says that Ms Smoker was “a candidate for sudden cardiac death”
[The Advertiser 09 July 1992]

It should be asked if she was informed of this prior to her operation. If she was not, then if Dr Manock is to be believed, there could well be clear evidence of neglect.

Charles Stewart 1992

Mr Stewart was aged 20. It was reported that he was involved in a police shootout at Kingswood in Adelaide. The report said that Mr Stewart robbed a service station and then took a family hostage in Seafield Avenue, before wandering to Tutt Avenue where he died about 2.45am. He was shot six times in the back, and once through the knee, by police marksmen.

The Coroner, Mr Ahern, heard evidence from Dr Manock that none of the shots fired by the police was fatal. One also presumes, that it was Dr Manock’s view, that it was also the case that their cumulative effect was not fatal either. Dr Manock pointed out that although the police .38 calibre bullets passed through Mr Stewart’s pericardial sac (the heart) and through the upper lobes of both lungs, they would not have been fatal.
[The Advertiser 29 Jan 1992]

The Coroner of South Australia

Complaint

The Coroner Mr Wayne Chivell was in error in his conduct of matters related to Mr Keogh’s trial.

Particulars

The Coroner is Mr Wayne Chivell.

Dr Manock was the principal Crown witness who gave evidence as to the cause of death at the trial of Mr Keogh. Dr Manock was referred to by the prosecutor and the trial judge as the most experienced of the four forensic pathologists to give evidence at the trial.

The Coroner knew that Dr Manock was not working in accordance with accepted standards within the profession. He failed to take appropriate remedial steps to ensure that the shortcomings and deficiencies in his work were corrected, or that appropriate action was taken in relation to his findings. 

At the time at which Dr Manock was giving evidence in Mr Keogh’s trial, the Director of Public Prosecutions was aware that Dr Manock’s credibility and expertise had been subjected to serious challenge in the Infant Deaths Coronial Inquiry, by Mr Alan Moss, the Deputy Crown Solicitor. This had been taking place in the Coroner’s Court in Adelaide during 1993 and 1994. The Coroner determined that:

In important respects Dr Manock had not been truthful in his evidence.

That Dr Manock had failed to act in accordance with basic autopsy procedures.

Dr Manock had failed to properly record his findings.

Dr Manock had seen things which could not have been seen.

That serious crimes may well have gone uninvestigated as a result of Dr Manock’s findings.

Contrary to subsequent comments by the Coroner and by Mr Rofe QC, these criticisms of Dr Manock were not restricted to the fact that the matters involved in the Infant Deaths Inquiry involved paediatric deaths.

Whilst the trial of Mr Keogh was taking place, the Coroner Mr Wayne Chivell determined not to release his report in the matter of the Infant Deaths Inquiry. His report had been completed at that time. Two days after the verdict in Mr Keogh’s case, the Coroner released that Report. It was only at that stage that the true extent of Dr Manock’s incompetence was revealed. In the affidavit sworn on 17 December 1996 attached to Mr Keogh’s earlier petition (as Annexure “J”) Mr Michael Sykes, solicitor, stated as follows:

“I have also spoken with the Coroner Mr Wayne Chivell who published the Finding. In the course of a telephone conversation on 18 September 1996 he informed me that he was sensitive to the fact that Mr Keogh’s second trial was proceeding at the time when he was ready to publish his finding. He knew that Dr Manock was a principal Crown witness in the trial and to avoid a mistrial he decided of his own volition to delay publishing the Finding until after the trial had concluded.” 

The effect of this decision by the Coroner was that the jury in the Keogh trial was required to make a choice between the credibility of evidence given by Dr Manock and Dr James and that given by Professors A and B in the case. At that time, the jury had been unaware of matters which cast severe doubt on the competence and professional integrity of Dr Manock and Dr James.

In similar circumstances in the United Kingdom, in the case of Trevor Campbell, determined by the Court of Appeal on 21 January 1999, the Lord Chief Justice, Lord Bingham, Mr Justice Scott Baker and Mr Justice Curtis ruled that the conviction was unsafe, and accordingly quashed the conviction of Mr Campbell who had been convicted of murder.

The Coroner had requested Dr Thomas to investigate the infant deaths prior to Xmas 1993. Dr Thomas’s scathing Report on Dr Manock’s work was with the Coroner on 11 February 1994.

It was only AFTER this that the Coroner appointed Dr Manock to undertake the autopsy of Ms Cheney. The appointment of a pathologist to conduct an autopsy is a Coronial appointment.

The Coroner informed the police that the death of Ms Cheney was considered to be a murder on Wednesday 23 March 1994. It was improper for Dr Manock to have been communicating directly with the police in relation to these matters. Given that he was appointed by the Coroner to conduct the autopsy on behalf of the Coroner, the information to the police should have been provided through the Coroner’s office. If this had been done, then the police would not have set about investigating a “murder” without any proper basis for doing so. In this respect the Coroner is responsible for ensuring that Dr Manock had conducted all appropriate inquiries and investigations, and had properly recorded his findings in relation to them. Clearly this was not done.

There was no proper basis for the Coroner to be requesting advice from Dr Manock or the police as to whether the disposal of the body could proceed. There was no proper basis for Dr Manock or the police to be providing such advice to the Coroner. The Coroner consented to the cremation of Ms Cheney on Friday 25 March 1994 on the basis of opinions provided to him by Dr Manock and a police officer. At that time the Coroner had not taken any steps to ensure that Dr Manock’s work had been correctly conducted or recorded.

In the circumstances, the Coroner should not have appointed Dr Manock to undertake the autopsy of Ms Cheney. The Coroner should not have consented to Ms Cheney’s cremation.

The proper responsibility of the Coroner is to establish the cause of death and provide that information to the Registrar of Births Deaths and Marriages. It is not the responsibility of the Coroner to consent to a cremation. The proper responsibility of the Coroner is to determine whether a body may be disposed of. Once that consent has been given by the Coroner, the method of determining how that may be done is that of the Registrar of Births Deaths and Marriages.

The Registrar of Births Deaths and Marriages

Complaint

The Registrar of Births Deaths and Marriages was in error in his conduct of matters related to Mr Keogh’s trial.

Particulars

The Registrar of Births Deaths and Marriages, failed to ensure that the relevant work of the Office of the Registrar of Births Deaths and Marriages was completed in accordance with accepted standards. This has resulted in a serious miscarriage of justice in relation to Mr Keogh’s trial.

The Registrar of Births Deaths and Marriages is the only person able to make a lawful determination so as to allow a cremation to take place. The Act under which the Registrar operates states that where a cause of death has been established by documentation from two medical practitioners, and that there was a natural cause of death, then the Registrar can give permission for the disposal of the body by cremation or burial. 

A sudden or unexplained death comes within the jurisdiction of the Coroner. In such circumstances, the Registrar can only allow the body to be disposed of by way of cremation or burial if the Coroner has determined the cause of death, and provided notification of that to the Registrar in appropriate form. At no time prior to the disposal of Ms Cheney’s body, had the cause of death been properly determined.

A Registrar can register a death, but cannot approve of disposal by way of cremation, without a cause of death being appropriately notified. The Registrar can approve a burial after appropriate advice from a Coroner and where the Coroner provides a burial certificate to the Registrar. 

In the case of Ms Cheney, the Attorney General’s Dept has advised that the Registrar was provided with a certificate from the Coroner which allowed for burial only. However, Ms Cheney’s funeral service took place on 30 March 1994. The Centennial Park Cemetery has informed us that they cannot provide a date on which Ms Cheney’s cremation took place, but they have told us that Ms Cheney was cremated. If Ms Cheney has been cremated then it would in the circumstances constitute an unlawful cremation. If Ms Cheney has not been cremated then Mr Keogh’s legal advisers have been seriously misinformed.

It is understood that Ms Cheney’s cremation took place on or about 30 March 1994.

The Registrar was not advised of Ms Cheney’s cause of death until 12 May 1994.

Mr Keogh was arrested on 7 May 1994 before the cause of death was established.

The South Australian Police Force

Complaint

The South Australian Police Force (and its officers, employees, servants or agents) has acted inappropriately in its investigation of matters related to Mr Keogh’s trial.

Particulars

The various employees, officers, servants or agents of the South Australian Police Force, knew or should have known that Dr Manock was not working in accordance with accepted standards within the profession. Insofar as they worked with Dr Manock, or in relation to the cases referred to herein, they too failed to work in accordance with the accepted standards of their profession. They failed to ensure that the relevant work of the Forensic Science Centre was completed in accordance with accepted standards within the profession. In so far as they became aware of shortcomings in the work of the South Australian Police Force or of Dr Manock or of the Forensic Science Centre, they failed to take appropriate remedial steps to ensure that the shortcomings and deficiencies were corrected. All of the above, individually and collectively have resulted in a serious miscarriage of justice in relation to Mr Keogh’s trial.

The Police Forensic Procedures Manual (PFPM) is part of the Police General Orders, and establishes the regulatory framework under which the police operate. The PFPM states that the provisions which it contains are the “minimum operating standards” which are to be adhered to. In many respects those standards and procedures were ignored in relation to Ms Cheney’s death. The Director of Public Prosecutions has stated that he does not know of the existence of this manual, and that he has never seen it. The DPP would not be in a position to assess the adequacy of police investigations without reference to this manual.

No cordon or barrier to the scene

At no stage did the police establish a cordon or barrier to the scene at which the death is thought to have occurred. The PFPM states that they are required to do this for all sudden and unexplained deaths. All such deaths are stated by the PFPM to be regarded as being suspicious deaths, until an appropriate determination is made to the contrary. The obligation is obviously to establish the cordon to the scene at the outset of the investigation, not at some later stage.

No guard appointed to control entry and exit to the scene.

No guard was appointed to control entry and exit to the scene and to record details of those entering and leaving the scene. Although a police officer was stationed at the entrance to the premises, he failed to control or record entry and access to the premises. It is stated that the police are required to do this in the Police Forensic Procedures Manual.

Crime-scene investigators did not take control of scene

The Police Forensic Procedures Manual states that crime scene Investigators are to take control of the scene where a suspicious death has taken place. It also states that any unexplained death is to be treated as being suspicious. It was therefore inappropriate to have allowed the operational police officers, the various family members and others to have access to the scene, and to have allowed them to interfere with it (and the body) before it was properly examined by those crime scene investigators, and then formally handled over to the operational police officers.

No one wore protective clothing

None of the police who attended at the scene that evening wore any of the protective clothing which was required by the Police Forensic Procedures Manual. This was despite the fact that there was a very high likelihood of there being bodily fluids and vomitus material in the vicinity.

No objective medical or physical observations made at scene

No proper objective medical or physical observations were made and recorded at the scene as to the state or condition of the deceased. Nor was other appropriate data collected for forensic pathology considerations. If this had been done the numerous discrepancies between the various witness statements of the officers concerned, would not have occurred.

Ambulance officers statements not taken until months later

At the trial it was left to the recollection of ambulance officers to determine if the carpet in the bathroom and the bedroom was wet or dry. This was crucial evidence, for it went directly to the integrity of Mr Keogh, and whether he had attempted to save the life of Ms Cheney. The ambulance officers admitted that although this evidence was seen by them to be crucial, they had not written these details down at the time. Their statements expressing concerns were not made until many months after the event.

Timings of ambulance officers unlikely to be accurate

There is clear evidence in the statements of the time at which the ambulance officers say that they arrived at the scene. They have set out the procedures which they say they had completed. The time is recorded in various statements of the time at which they were on the pavement outside the property when the police arrived. The recorded activities are inconsistent with the timings which the ambulance officers gave and which are recorded in the various police statements.

The search party did not preserve evidence re items moved

At various times on that night and during the next week, the police officers were despatched to all of the rooms of the house to collect items. There is nothing to show that they were concerned to see if there was any evidence that the items had been recently moved. Given that Ms Cheney was dead, and that there were containers of tablets in the house it might well have been important to determine if Ms Cheney could have taken any of them that evening. Her fingerprints on the containers (or indeed Mr Keogh’s) or rings of dust or other marks where the containers were would all have been useful indicators for or against recent use of those containers. The various officers who were part of the “search party” at the house, were not trained crime-scene investigators. None of them appear to have worn any of the special clothing which such officers are required to wear in accordance with the Police Forensic Procedures Manual to prevent contamination of the scene.

Audit trail of photographs has not been established

No audit trail has been established with regard to the photographs taken at the scene. It is important to Mr Keogh’s defence to know who examined the photographs on behalf of the police. Why there was no mention in the pathologist’s report of the wound on Ms Cheney’s head, nor any mention of the appearance of oedema and swelling of the face, the body and behind the ears(s). Mr Keogh’s advisers need to know if and when Dr Manock had access to these photographs, if at all, and when they became available to the prosecution and defence lawyers.

Anna’s body was “tidied up” at the scene

The photographs taken at the scene show that Ms Cheney’s body was “tidied up” at some stage. It appears that during the course of the evening, her make-up was improved, her hair had been combed, and the swelling to her head and face was reduced. Whilst this is evident from the photographs which have been made available, there is no reference to these facts in any of the statements which have been made available, or in the autopsy report. 

The body interfered with by unauthorised people at the mortuary

A number of people had access to Ms Cheney’s body at various times in the absence of a crime scene officer. It is clear that Constable Walkley went to inspect Ms Cheney’s body at the mortuary without anyone else being present. Ms Walkley was the Constable attached to the Coroner’s Office, and had been in that position for some twelve years. She would have understood that those actions of hers were not in accordance with the Police Forensic Procedures Manual. The autopsy was undertaken without a crime-scene officer being in attendance. These actions were contrary to the requirements of the Police Forensic Procedures Manual.

No attempt to exclude bruising as result of movements that evening

The photographs taken at the scene show that Ms Cheney’s body was moved very substantially, first to one side and then to the other. During these movements, Ms Cheney’s leg can be seen pressed against the doorframe. Ms Cheney’s body was physically lifted by a number of people and removed from the premises before being placed on a stretcher. No proper descriptions have been made available of how or when these things were done or by whom. At the trial, it was alleged that bruises were subsequently found on Ms Cheney’s left leg. It was asserted or inferred that such bruises must have resulted from a grip by Mr Keogh. Other possible candidates as leg-grippers could have been any of those moving the body that evening or subsequently. No statements were taken from them, and no evidence was given at the trial of Mr Keogh which sought to exclude this possibility. 

Police should develop photos – not the Forensic Science Centre as claimed

The Forensic Science Centre (Dr Kobus) has explained that the Forensic Science Centre did not take colour photographs at the autopsy, “because the Forensic Science Centre could not develop its own colour photographs.” However, the Police Forensic Procedures Manual states clearly that it is the responsibility of the police to take such photographs and to have them developed.

The Police Forensic Procedures Manual states that:

“Crime scene investigators are to photograph the autopsy examination, preferably using 6 x 7 format, colour film, and electronic flash. Photographs should include:

General photographs of the body bagged
General photographs of the body un-bagged
Mid-range photographs of the body
Detailed photographs of the body
Any other photographs at the request of the pathologist.”

None of these things were done. There are no colour photographs of the autopsy at all. The black and white photographs, which were taken, require serious investigation as to the circumstances in which they were taken, and the reasons for which they were taken.

Polylight used to take black and white photographs

It is clear that a “polylight” was used during the taking of some of the black and white photographs. This is not a standard or recognised lighting source for photography, and this procedure requires to be explained. The Police Forensic Procedures Manual states that the polylight is to be used for “biological fluids and textile fibres”. It does not mention anything about the use of this method for “enhancing bruises”. The proper method to search for suspected bruising is to reflect the tissue over the area in question.

Colouring substances used during taking of photographs

The photographs taken at autopsy disclose that an “inky” material, or colouring agent was being used. This is not a standard or recognised procedure and requires to be explained.

Unacceptable inconsistencies in police evidence – eg distress or acting

One constable in his statement says that “Keogh was clearly distressed and there was nothing suspicious from my talk with him”. Another constable said, “Keogh was visibly distressed and after 5 minutes, at his request, he returned to the house to be with the deceased”. Another constable said, “here was an adult male, very distressed and crying overtly. He was unable to speak because of his emotional state”. It is clearly important to any evaluation of the circumstances to ascertain whether Mr Keogh was genuinely distressed or not. The wording used in many of the statements makes it clear that those who expressed a view, or wrote their statements up soon after the events of that evening, were in no doubt that his distress appeared very genuine. So much so that all of the police officers in attendance that evening were convinced by the end of the evening that there were “no suspicious circumstances”.

Constable Walkley however, uses the expression “crocodile tears” in reference to Mr Keogh’s condition that evening. We know that Constable Walkley was one of the key players in the development of suspicions around Mr Keogh’s involvement in this case. She was to say subsequently that “Keogh was one of the most evil men she ever met”, and that if it were not for her he might have walked free. It is important that we establish the basis for the development of these views. This is necessary, especially as it appears that Constable Walkley was one of those responsible for “tidying up” Ms Cheney’s body that evening. Given Constable Walkley’s extensive experience in her attachment to the Coroner’s Office, she would have known that such actions were contrary to established or proper procedures.

Who was in charge of scene during the evening?

In the light of the considerable confusion surrounding the events that evening, it has to be determined how the police case was managed. Who was in charge, and what procedures were put in place?

How were communications handled?

How were communications with the Forensic Science Centre, the DPP’s office, and the Coroner’s Office being managed? What were the lines of communications?  To what extent are the police independent of the DPP’s office? Why did they not follow up on the aspects of the case which indicated that Ms Cheney had a severe allergic reaction, as evidenced by the photographs which they had taken, and which must have been apparent to the police at the scene that evening?

Why were phone calls being made from private house of neighbour?

Why were senior police officers going to the house of a neighbour to make telephone calls instead of using their own phones or radios? Who were they calling, and why did they not want those calls to go through the regular channels? Clearly we need access to the telephone records of that neighbour to determine to whom the calls were made.

Why were crime-scene investigators not present at autopsy which was totally inadequate?

Why were the crime-scene investigators not present at the autopsies which were said to have been done on the Sunday and the Monday?

Why did they not insist upon proper documentation and photographs for the autopsy? They would have been well aware of the criticisms of Dr Manock which had been made in the recent Coroner’s Report into the Infant Deaths, and they would have known that Dr Manock’s “procedures” had been subject to serious criticism.

Why have the police not investigated the “missing” negatives for the photographs, which were taken at the Forensic Science Centre in this case?

Why has Dr Manock not been investigated by the police?

Why have the police not investigated the fact that the controls on Dr Manock’s microscope were locked solid due to lack of servicing at that time?

Why have the police not investigated the circumstances of Manock’s appointment at the IMVS, and the supporting documentation and other evidence which he put forward in support of his application?

Investigation of Dr Manock after the Perry case in 1982

Given that the High Court of Australia had determined that the forensic procedures in the Perry case constituted an “appalling departure from accepted standards of forensic science” it should be determined what steps were taken by the police at that time to ensure that those standards were improved.

Investigation of Dr Manock after the Coroner’s Report on Infant deaths?

Was Dr Manock investigated by the police after the Coroner’s Report into the Infant Deaths, where the Coroner determined that Dr Manock’s conclusions had the opposite effect of its proper purpose? Dr Manock had clearly prevented the investigation of very serious crimes. The Coroner suggested that Dr Manock may not have done the histology which he claimed to have done. Why was police investigation of these issues, not undertaken at that time?

Police photographs inconsistent with evidence put to the court

The police colour photographs show the possible existence of an allergic reaction, and damage to Ms Cheney’s body not noted at the autopsy. They contain clear evidence, which was inconsistent with the evidence being put to the court. Ms Cheney’s extensive oedema was clearly not consistent with her being “fit and healthy”. The injury to her forehead was not mentioned in the autopsy report. The track pants indicate that Mr Keogh used them to wipe her face before the ambulance officers arrived.

Why did police not investigate interference with the body?

The photographs at the scene indicate that Ms Cheney’s body was “tidied up” that evening, before her body was removed. This is clearly inappropriate behaviour and should have been explained.

Did police interview people said to be present at post-mortem?

Have the police interviewed the people said to be present at the Forensic Science Centre whilst these autopsy procedures were being conducted, in order to ascertain what exactly was being done?

Have the police investigated Dr Manock’s appointment to College?

Have the police investigated the circumstances of Dr Manock’s appointment to the College of Pathologists? Presumably the College would have sought some confirmation from the Police in South Australia prior to making that appointment.

Why was Manock communicating directly with investigating officers?

Why was Dr Manock communicating directly with police officers, rather through the Coroner’s Office as he is obliged to do?

Video recording would have rendered speculation unnecessary

The Police Forensic Procedures Manual states that, if necessary, the crime scene officer is to record the scene on a video recorder so that it can then be shown to the operational police officers, who are to remain outside the cordon. In this way, the officers in charge of operational matters can get on with their job, whilst the forensic examiners get on with theirs. No video of the scene, or the rooms or the contents of cupboards was taken, before the investigating officers conducted their search operation. The only objective evidence we have of the scene that evening is a few coloured photographs of Ms Cheney lying on the floor, and of incidental parts of the bedroom caught up in those photographs.

Deceased’s father allowed to empty bath – no samples taken of water

Later in the evening, the police were so unconcerned about the preservation of evidence and information from the scene that Ms Cheney’s father emptied the bath water after the police had left the house, and before samples of the water had been taken. Whilst it was later suggested that Mr Keogh had acted suspiciously, in tidying up the house afterwards, no one has suggested that Dr Cheney was acting suspiciously in emptying the bath, or indeed that others had acted suspiciously in tidying up the body of the deceased. It was later realised that the bath may well have contained valuable evidence in enabling people to interpret what had happened. There was, for example, some material in the water which might have been bath salts, or it might have been vomit or other substances. Whilst some six or eight police officers looked at the bath, not one of them thought to take a sample of the water.

No temperatures recorded - of body – ambient temperature - temperature of water

No temperatures were taken by any of the police or ambulance officers involved. The area ambient temperature was later found out from the Bureau of Meteorology. That evening, no one took ambient - water - or body temperatures as required by the Police Forensic Procedures Manual.

Police officer says statement obtained from ambulance officer – where is it?

Shortly after the ambulance officers finished their procedures, one of them then went out and spoke to a police officer. That police officer says:

“I spoke to [that ambulance officer], and then returned to the bedroom to speak to [police] officers Fielding and Man. [The ambulance officer] and I left the house to go to the car so that I could get a statement from him.”
[Brett Williams – 9.46pm]

It is important to note here, that the police man is “getting a statement” from the ambulance officer immediately after he was attending to Ms Cheney. Presumably if the ambulance officer had any concerns at that time, he would obviously have mentioned them to the police officer. However, we have no record of such concerns being expressed. We have not been provided with a copy of the ambulance officer’s “statement” which the police officer refers to.

Ambulance officer says later that evening “no suspicious circumstances”

It is also important to note that the ambulance officer later declared that evening that there were “no suspicious circumstances”. The only thing we can infer from this is that either the ambulance officer did not express his concerns to the police officer earlier in the evening, when he was giving him a statement. Alternatively, the police officer chose to disregard those expressions of concerns.

The St John’s Ambulance Service

Complaint

The St John’s Ambulance Service of South Australia (and its officers, employees, servants or agents) has acted inappropriately in its conduct of matters related to Mr Keogh’s trial.

Particulars

The various employees, officers, servants or agents of the St John’s Ambulance Service of South Australia, failed to act in accordance with accepted standards within the profession. As a result, their actions have resulted in a serious miscarriage of justice in relation to Mr Keogh’s trial.

Mr Murgatroyd first statement factual  - arrives 9.38pm stops 9.55pm

There are two statements from Mr Murgatroyd which state what happened that night. In his first statement he says that he arrived at the house at 9.38pm.

“I attended at no 13 with ambulance officer Stevenson. We were called with regard to a person having collapsed in a bath. On arrival we waited for a moment or two for a dog to be removed from the hallway. We went to the front room. There was a male person over a body lying on the floor. We commenced CPR but found that the airway was full of fluid and we could not get air into her lungs. We stopped resuscitation attempts at 9.55pm after working on her for 10 minutes. We were unable to clear airways which was why we ceased resuscitation. A short time later the police arrived and I had a conversation with them.”
[Statement undated – Paul Murgatroyd – ambulance officer]

We can see from this that it appears to be a fairly straightforward factual account of the chronology of events. We understand that this is one of the first statements which was given by Mr Murgatroyd. One would have thought that such a statement would include all of the relevant facts, and certainly any observations, which might reflect any “concerns” which he would have had.

Mr Murgatroyd Later expresses concerns about resuscitation

Mr Murgatroyd’s next statement is not given until some months after the incident. In that statement he says:

“When we went into the house I went to the body which was in a supine position. There was no vomit near body or on it at the time. The hair felt damp but the skin was dry. The woman had a towel around her midriff which did not seem wet. The male person said he had been doing CPR. I thought this to be unusual as when I examined the body I saw water in the mouth. In my view, any attempt at manual compression would cause vomit and water to spill out. There was no sign in the area of the body of any vomit or water which would have taken place if any effort was made to do CPR. I examined the bathroom area and could see no sign of vomit or water on the floor. The bath water was slightly cloudy but there was no sign of vomit in the bath. With any attempt to perform CPR large amounts of water came out.”

He is now making a whole series of observations, which apparently reflect some “concern” which he now says he had at the time. There was no vomit near the body or on it. The hair, body and towel were not wet. There was no water on the floor in the living room or in the bathroom. He thought the explanation about Mr Keogh doing CPR was “unusual”. “In my view” he said, “any attempt at manual compression would cause vomit and water to spill out”. He does not tell us how this view was formed. It certainly cannot be on the basis of experience, because this is the first adult drowning which he had attended.

Ms Stevenson’s first statement factual

There is a similar parallel in the statements, which were given by Ms Stevenson. Her initial statement, like Mr Murgatroyd’s is a more straightforward factual account.

“I attended at no 13 Homes Avenue. There was a dog at the door, and we were held back for a moment or two whilst the man inside put the dog away. I went to the bedroom where I saw a female on floor – the man was now hunched over her crying. I asked him to go out and he went outside. We connected her up and found her to be a-systolic – clinically dead. We started CPR but all we could get was water and vomit, which came from her mouth. I would say that her hair was damp but not wet. I looked at the bathroom floor which was dry. I noticed that the bathmat was screwed up. The man said he had been doing EAR – which was mouth to mouth resuscitation. I noticed that the bath was three quarters full. I said that I was sorry but there was nothing further that we can do. His hands were over his face crying. I said is there anything I can do – he hugged me and kept his arms around me. Then relatives started coming in. I heard him say “my back is sore – I hurt it today”. He said he wanted to say goodbye to her.” 
[21 July 94 – Statement - Kerry Louise Stevenson – ambulance officer]

There are no expressions of concern being raised in this statement.

Ms Stevenson later expresses concerns

In Ms Stevenson’s statement, which she makes some months later, she says:

“I remember that when we arrived she was dry and the carpet was dry. There was no water or vomit on the carpet. When we tried to ventilate her fluid and vomit came up. [Other ambulance officers] had arrived. I am of the view that if a person with first aid skills had attempted resuscitation, then we would expect to find fluid and vomit in the upper airway. As far as I am aware this area was clear. There was water in the bath and it was still warm – but not as warm as I would use for a bath."

Ms Stevenson is now referring to a whole series of apparent observations, which she now thinks to be significant, but which were not included as part of her previous statement. No water or vomit on the carpet, and the airway was clear “as far as I am aware”. She is now indicating that she thinks that Mr Keogh did not attempt resuscitation. Again, as with Mr Murgatroyd, the observations upon which the concerns were based should have been noted from the outset. If she genuinely had those concerns, at that time, then they should have been raised at the outset.

Content inconsistent – not “expert” opinion

It is important to appreciate the capacity in which these statements are being made. The two obvious categories are that they are either witness statements or the expression of some expert opinion. It is clear that they cannot constitute “expert” opinion, because neither of the ambulance officers could be said to have either the experience or learning upon which such expertise could be based. Therefore the statements could only express their observations about what happened, but not any expert or medical opinion based on those observations. Ms Stevenson says that if a person with first aid skills had attempted resuscitation, she would expect to find fluid and vomit in the airway. Mr Murgatroyd says that this is exactly what they did find. When Ms Stevenson says, “as far as I am aware, this area was clear”, it is hardly expressed in the most confident of terms. Certainly if it were to be used as the basis for an allegation of murder, one would have expected her to have made absolutely sure of what it was she was saying – if she had thought of it at the time. However, the most likely interpretation, is that she was very inexperienced in these situations, and was most likely led by the police into making statements which were not consistent with her actual observations, or thought processes, at the time.

At the trial there was a “voir dire”. Quite correctly, Mr Keogh’s counsel objected to anything which the ambulance officers might have to say which was not a matter of direct observation. In other words, they were not allowed at the trial to express the view that Mr Keogh had not attempted to resuscitate Ms Cheney.

However, what they could do was to include their observations about the scene which gave rise to those concerns, and which allowed the prosecution to argue that Mr Keogh had not attempted to resuscitate Ms Cheney. One would have thought that the prosecution would want to know why those concerns were not dealt with at the time of Ms Cheney’s death. We would also have expected Mr Keogh’s counsel to have explored the “late emergence” of those observations and the reasons for that delay. We would also have expected him to make inquiries as to why the ambulance officers had not recorded those obviously important “observations” at the time at which they occurred.

There was some reference by the ambulance officers to the effect that they could remember the circumstances which they referred to, although they were not contained in their notes.
[Murgatroyd at trial - read from your note your observations of this – something I can independently remember –any note of condition of carpet on arrival – no – notes taken shortly after as record of what happened – no from memory – notes were written at scene –  p100]

However, it would be quite remarkable if such inexperienced officers could remember anything very much about the detail of that evening. In effect Mr Keogh was denied the ability to mount a proper defence to these allegations, because of the considerable delay in these issues being raised.

DPP wanted to block off line of defence

If the ambulance officers only raised those concerns with the police many months after the event, then we have to ask questions about how they came to raise those concerns at that time. The most likely explanation is that the police, maybe at the suggestion of the DPP’s office, became aware of the significance of Mr Keogh’s claims that he attempted to resuscitate Ms Cheney. Clearly that claim is not consistent with his having murdered her. No doubt, in preparing for the trial, the DPP’s office asked the police officers to check out Mr Keogh’s account with the ambulance officers. This may explain the late emergence of new elements to their recollections.

Contradictions in evidence of ambulance officers re timing

A Police officer said:

“At 9.46pm we were met at the front of the premises by ambulance officers Murgatroyd and Stevenson from St Johns.”

The timings are very significant. The police officers are very precise about their time of arrival (9.46pm) – and that they met the ambulance officers outside the house. We know the ambulance officers arrived at 9.38pm. This means that there is only 8 minutes between the time of the arrival of the ambulance officers, and their meeting with the police officers outside the house. The ambulance officers admit that they were delayed admission by the dog in the hall – they say that they were held back by “a couple of minutes”. They would also have taken some time to go into the house – and attach Ms Cheney to the monitoring equipment. Then they would have taken time for them to pack the equipment away and return to the street. It is clear that they cannot have been attempting to resuscitate Ms Cheney for 10 minutes as they claim. 5 minutes might even be generous. Independent professional evaluations will indicate that this is too little time within which ambulance officers could make a proper professional evaluation of Ms Cheney’s condition.

Ambulance officer says water cloudy – but no vomit in the bath?

Mr Murgatroyd also said:

“I examined the bathroom area and could see no sign of vomit or water on the floor. The bath water was slightly cloudy but there was no sign of vomit in the bath.” [Emphasis added]

It is yet to be explained how Mr Murgatroyd knew that the “cloudiness” had nothing to do with vomitus material? This is somewhat similar to the observations of the constable who said:

 “the bath was three quarters full – with almost clear water. There was nothing in the bath” . [Emphasis added]

If the water was “almost clear” then there clearly must have been something in the water, otherwise it would have been clear.

Bathroom floor wet or dry?

Ambulance officer Ms Stevenson said in her statement that the bathroom carpet was dry. She also said that she could recall that the floor in the bathroom was dry and that the bathroom mat was dry. This sort of detail was important to the ambulance officers’ evidence in that they were also to add that the carpet in the living room was also dry, which was taken to be evidence of the fact that Mr Keogh did not attempt to resuscitate Ms Cheney. Mr Cheney said the fact that the floor “was not wet” in the bathroom also seemed strange.

Many other witnesses that evening stated that the floor was wet. That the bathroom mat was very wet. One statement says that the witness picked it up and it was heavy with water.
[Walkley 25 June - the bath mat was scrunched up and it was heavy with water The photographs taken at the scene show clearly that the carpet under the body was wet. It is clear that the dampness of the carpet could not have been caused by the water coming from the mouth of the deceased as a result of the ministrations of the ambulance officers]

Ambulance officer Ms Stevenson says no fluid or vomit in the upper airway

Ms Stevenson says in her statement of 4.1.95 - “I am of the view that if a person with first aid skills had attempted resuscitation, then we would expect to find fluid and vomit in the upper airway.” She does not state the basis for this view. She then goes on to say that “As far as I am aware this area was clear”. The obvious inference to be drawn was that the absence of water in the upper airway, would lead her to the conclusion that Mr Keogh had not done CPR as he claimed to have done.
[This observation appears not to be consistent with the earlier statement made by this officer in July 94, which indicated that the upper airway was not clear]

Ambulance officer Mr Murgatroyd – vomit and water in the upper airway

Mr Murgatroyd says in his statement that - “the male person said he had been doing CPR. I thought this to be unusual as when I examined the body I saw water in the mouth. In my view, any attempt at manual compression would cause vomit and water to spill out.” Now Mr Murgatroyd is saying that it was the presence of water in the upper airway, which led him to the conclusion that Keogh had not done CPR.

Both agree Keogh did not do CPR – but based on contradictory facts

This contrast in their statements is confusing. The one thing on which they are both agreed, is that Keogh could not have done CPR. Yet the facts on which they base these inferences are diametrically opposed.  In other words, both the presence and the absence of water in the upper airway, would lead them to the conclusion that Mr Keogh had not done CPR. Clearly this is an absurd situation. It would appear that whatever the facts were, the ambulance officers know that Mr Keogh did not do CPR, and thus give rise to a clear inference of bias, the basis of which has yet to be determined.

Conclusions articulated but not the reasoning upon which they are based

What is clearly missing in this situation is the statement of the reasoning, which allows the ambulance officers to make those inferences. They might say, for example, as Mr Murgatroyd did that if Mr Keogh had done CPR, then he would have expelled water from Ms Cheney’s airway, and therefore one would not expect to see water in the mouth after an attempt at CPR. However, if this was his line of reasoning, then we would know from his own observations that it must be incorrect.

What Mr Murgatroyd said in evidence at Mr Keogh’s trial was that Ms Cheney had water to her back teeth. When they rolled the top half of her body over, water escaped from her mouth. He then inserted the oral airway, but they got more fluid to the same level as before. They then rolled the whole body to the right, and more fluid escaped. They were trying alternately to suction – ventilation – suction. Then they attempted defibrillation, and further large amount of fluid came from the airway. What Mr Murgatroyd is telling us here is that whatever he tried to do, Ms Cheney’s airway filled with water and they could not get it clear. Yet he is also saying that if Mr Keogh had attempted CPR, the airway would have cleared and remained clear. These assertions by Mr Murgatroyd are plainly inconsistent, and not in accordance with the circumstances which he faced.

Their observations confirm Mr Keogh’s claims

Ms Stevenson suggests that Ms Cheney’s airway was clear when she first treated her but that “When we tried to ventilate her fluid and vomit came up”. She also said in her earlier statement that, “We started CPR but all we could get was water and vomit which came from her mouth”.

Both of those statements by Ms Stevenson indicate that Ms Cheney had both water and vomit in her airway. Given that she was lying on her back on the floor, then that fluid would normally drain to the lowest point, which would mean that it could be expected to be seen at the back of her mouth and throat. If it wasn’t seen there, then the only explanation for that would be that there was some mechanical obstruction in her throat. That some food or vomit had become lodged in her throat so as to cause an obstruction. Unless Ms Stevenson knew how hard it had been compacted, and what it was made of, she would have no idea whether it could have been dislodged by Mr Keogh’s attempts at CPR or not. The fact that this observation of Ms Stevenson’s is at odds with that of Mr Murgatroyd would indicate that their recall of this matter was unreliable. Mr Murgatroyd’s observations also accord with Mr Keogh’s statements in relation to this matter.

Mr Keogh made it perfectly clear in his statements that he wiped mucous from Ms Cheney’s  face using the green track pants which were nearby. The existence of this material on those pants is confirmed by the photographic evidence, which was produced in court, but not specifically referred to by counsel. No other people, who were in attendance at the scene that evening, claim to have wiped Ms Cheney’s mouth with the track pants.

Ambulance officer – no sign of vomit – yet mucous evident in photos of track pants.

When Mr Murgatroyd said that “There was no sign in the area of the body of any vomit or water which would have taken place if any effort was made to do CPR” then that statement by him is not consistent with the photograph of the track pants with the mucous material on them.

Anna’s father said that “The water was clear, but there were flecks of vomit or amorphous material on the bottom of bath”.
[Kevin Cheney statement 10 June]

Did the ambulance officers make any notes of their observations that evening – or at any time shortly after the event? If so, where are they? If they had not done so then one has to question their ability to recall such matters, so long after the event – and why it was not reported earlier. How many cases have they attended in the intervening ten months? Perhaps they could be asked some questions about some of those other cases – colour of car involved in accidents – colour of carpets when called to people’s home. It is clear that their evidence in court was given without reference to such notes. Yet they were asked no questions by defence counsel about their delay in giving their statement to this effect. They were not put to the test by the defence counsel on their inconsistent observations about the existence of water in Ms Cheney’s airway.

The Petitioner

The matters which the petitioner now seeks to put before the Court of Criminal Appeal have not previously been put to that Court on behalf of the Petitioner.

On the grounds that in the interests of justice, and that your intervention is necessary to avoid a miscarriage of justice and to address a justifiable sense of grievance, the Petitioner seeks that this petition be granted.

THIS THE PETITIONER THEREFORE ASKS that on the consideration of this Petition for the exercise of Her Majesty’s mercy having reference to the conviction of the Petitioner on information, the Attorney General refer the whole case to the Full Court pursuant to Section 369 of the Criminal Law Consolidation Act, 1935.

DATED this                             day of July 2002          

HENRY VINCENT KEOGH                                               

Petitioner..................................................................

CRIMINAL LAW CONSOLIDATION ACT 1935 - SECT 369

369 References by Attorney-General

369. Nothing in this Part affects the prerogative of mercy but the Attorney-General, on the consideration of any petition for the exercise of Her Majesty's mercy having reference to the conviction of a person on information or to the sentence passed on a person so convicted, may, if he thinks fit, at any time, either-

(a) refer the whole case to the Full Court, and the case shall then be heard and determined by that Court as in the case of an appeal by a person convicted; or 

(b) if he desires the assistance of the judges of the Supreme Court on any point arising in the case with a view to the determination of the petition, refer that point to those judges for their opinion and those judges, or any three of them, shall consider the point so referred and furnish the Attorney-General with their opinion accordingly.

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