IN THE MEDICAL BOARD OF SOUTH AUSTRALIA

AT ADELAIDE 18 November 2004

MEDICAL PRACTITIONERS ACT 1983

In the matter of a Complaint pursuant to section 54 of the Medical Practitioners Act 1983 made by Henry Vincent Keogh alleging unprofessional conduct on the part of Colin Henry Manock.

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

See also the Further Complaint 21 April 2005
Henry Keogh homepage
Article: Australian law on miscarriages of justice
Article: UK law on miscarriages of justice
Article: USA law on miscarriages of justice

Amended Complaint

Preliminary Matters

This Amended Complaint amends the previous applications and complaints dated

The Complainant Henry Vincent Keogh is a person who is aggrieved by the conduct of the Medical Practitioner Colin Henry Manock within the meaning of sub paragraph 54(1)(d) of the Medical Practitioners Act 1983 because, among other things, in or about 1994 the Medical Practitioner made incorrect assessments and drew incorrect conclusions concerning the death of one Anna Jane Cheney, which assessments and conclusions involved the Complainant. The Complainant is presently serving a term of imprisonment for the murder of Anna Jane Cheney. That conviction was based upon circumstantial evidence including evidence given by the Medical Practitioner.

The Complainant alleges that Colin Henry Manock’s conduct in relation to the practice of medicine has been at relevant times:
(a) Improper and / or unethical
(b) Incompetent and / or negligent
within the meaning and the definition of “unprofessional conduct” contained in sub section 5(1) of the Medical Practitioners Act 1983.

The Complainant seeks that the Complaint be laid before the Medical Practitioners Professional Conduct Tribunal by the Medical Board pursuant to section 58 of the Medical Practitioners Act 1983 it being a matter of sufficient seriousness and involving  significant issues of public interest such as to warrant it being referred to the Tribunal.

Particulars of Unprofessional Conduct

The following particulars of unprofessional conduct are advanced on behalf of the Complainant by reference to the definition of unprofessional conduct provided for in sub section 5(1) of the Medical Practitioners Act 1983. The Complainant relies upon the substance of the particulars referable to improper or unethical conduct in support of the allegation and contention that Colin Henry Manock is also guilty of incompetence in relation to the practice of medicine.  

Improper or Unethical Conduct in Relation to the Practice of Medicine

First particular

The Complainant alleges that Colin Henry Manock is guilty of improper and unethical conduct in relation to the practice of medicine. The Complainant, in addition to the following, refers to and repeats each of the particulars claimed to constitute incompetence in relation to the practice of medicine.

Second particular

In his formal response to the Medical Board dated 8 May 2003 Colin Henry Manock misled the Medical Board.

In that letter it was stated that, “The respondent attended at the scene after he was asked to attend.” That statement is misleading. It is also inconsistent with his reply quoted in the following particular. Appropriate standards of proper and ethical conduct determine that the decision as to whether a forensic pathologist is required to attend the scene in relation to any suspicious or unexplained death is a matter of professional judgment. It is a judgment which is to be made by the forensic pathologist concerned. 

The death of Anna Jane Cheney occurred on 18 March 1994. Colin Henry Manock completed his witness statement (autopsy report) on 29 April 1994. His first visit to the scene is said to have taken place on 27 June 1994 as is recorded in his report of 28 June 1994.

If Colin Henry Manock had considered attendance at the scene to be necessary in assisting him to determine the cause or manner of death, then he should have undertaken that visit prior to completing his witness statement (autopsy report). When completing that report, Dr Manock did not mention that it would be necessary to visit the scene in order to make those determinations.

Third particular

In the letter to the Medical Board dated 8 May 2003 it was stated, “Our client was not taken to the scene until several weeks following the autopsy and on his own request.” This answer is misleading. It is also inconsistent with his reply quoted in the previous particular. His attendance at the scene took place some three months after the autopsy and two months after the completion of his witness statement (autopsy report). Appropriate standards of proper and ethical conduct determine that a forensic pathologist is required to attend at the scene, or to give consideration to attendance at the scene, in relation to any suspicious or unexplained death, in a timely manner. If Colin Henry Manock had considered attendance at the scene to be necessary, then he would have recorded his considerations and his reasoning in relation to them in his autopsy report. He did not do so.

Fourth particular

Appropriate standards of proper and ethical conduct determine that the pathologist is to complete all relevant tests and investigations prior to the completion of the autopsy report and the establishment of a cause of death. In his investigation into the death of Anna Jane Cheney, Colin Henry Manock did not request the toxicological analysis of the relevant blood, tissue and stomach content samples, until some two months after the completion of his witness statement (autopsy report).

Peter David Felgate, in his toxicology report dated 23 June 1994, stated that he received certain items for toxicological analysis in relation to the death of Anna Jane Cheney. His report states, “On the 18 May 1994 at 1205 hours I received the following items from Dr C Manock, Forensic Pathologist, at the Forensic Science Centre.” The death of Anna Jane Cheney occurred on 18 March 1994. Colin Henry Manock completed his witness statement (autopsy report) in relation to the death on 29 April 1994. He did not state in that report that he was awaiting the outcome of further toxicological analysis. If Colin Henry Manock had required the results of further toxicological analysis in order to properly determine the cause of death, then he would have obtained the results of those tests prior to 29 April 1994.

Fifth particular

At the Committal proceedings in relation to the trial of Henry Vincent Keogh for the murder of Anna Jane Cheney, Colin Henry Manock agreed that he told the police of “ a certain mechanism whereby she could be deliberately drowned”. He said in those proceedings that he informed the police of this on the Sunday of the first autopsy procedure being 20 March 1994. There is no record of this conversation in the Coronial Office running sheet. Colin Henry Manock also stated in answers to further questions at that Committal proceeding, that whilst he could tell the police about his theory from that date, he could not and did not write it down until after he had visited the scene on 28 June 1994.

If a pathologist is developing and propounding a theory involving a certain mechanism whereby a deceased person could have been deliberately drowned, then that pathologist has an obligation in accordance with appropriate standards of proper and ethical conduct to record all such considerations and communications in a timely manner. In relation to his theory as to the cause of death of Anna Jane Cheney, Colin Henry Manock failed to do so.

Sixth particular

In accordance with appropriate standards of proper and ethical conduct, a pathologist has an obligation to report accurately and completely in relation to his inquiries and investigations. At the Committal proceedings in relation to Henry Vincent Keogh, Colin Henry Manock stated that, “On the Sunday morning of the autopsy I rang the police at Holden Hill CIB and I spoke to a detective, I don’t know his name, but the conversation is recorded in the Coroner’s Office running sheet.” The entries in the Coronial Office running sheet for the relevant days do not disclose such a record of that conversation.

Seventh particular

In accordance with appropriate standards of proper and ethical conduct, a pathologist has an obligation to report accurately and completely, in relation to his inquiries and investigations. Whilst Dr Manock has stated that on the morning of the autopsy he telephoned the police at Holden Hill police station to inform them of his theory involving a certain mechanism whereby a deceased person could have been deliberately drowned, he also entered or caused to be entered onto the Coronial Office running sheet, an entry which stated that the body of the deceased Anna Jane Cheney would be available to be released the following day (Monday 21 April 1994) after photographs had been taken. That entry is not consistent with his evidence at the Committal proceedings in relation to the death of Anna Jane Cheney that the cause of death was possibly a forced drowning, and that he notified the police of this possibility on the Sunday of the first autopsy procedure.  

Eighth particular

In accordance with appropriate standards of proper and ethical conduct, a pathologist has a duty to ensure that in an inquiry into a sudden or unexplained death, all appropriate and reasonable investigations are completed before the disposal of the body of the deceased takes place. The Coronial Office running sheet records that the permission of Colin Henry Manock was sought for the disposal of the body, in writing, by the Coroner, before the Coroner would agree to the disposal of the body of Anna Jane Cheney. The Coronial Office running sheet records that such written permission was obtained from Colin Henry Manock.

At the time at which he gave that permission, Colin Henry Manock knew or ought to have known that his investigation as to the cause of death of Anna Jane Cheney, and the records in relation to it, were manifestly inadequate. In particular, he should have ensured that his observations, investigations, inquiries and records in relation to the cause of death of Anna Jane Cheney had been checked by a competent and independent pathologist, before he agreed to the disposal of the body. He did not do so.

Ninth particular

In the letter to the Medical Board dated 8 May 2003 it was stated as follows, “Dr Manock was provided with photographs of the scene and did review them.” If he had reviewed the photographs, then he would have observed relevant marks on the body of Anna Jane Cheney which had the appearance of oedematous streaks, weals or blisters in the upper left quadrant of the body. He would have observed interference to the body and in particular the fact that makeup had been reapplied to the face of Anna Jane Cheney. He would have observed mucous stains on the track pants which were lying on the bed adjacent to the body of Anna Jane Cheney. If Colin Henry Manock had observed those features then he would have recorded them and his reasoning in relation to them as he would be required to do in accordance with appropriate standards of proper and ethical conduct. He did not do so.

Tenth particular

In the letter to the Medical Board dated 8 May 2003 it was stated that “Dr Manock did review all statements as and when provided by the police.” This statement is misleading. Appropriate standards of proper and ethical conduct require that a forensic pathologist should review all relevant witness statements, and in particular those of the family, police, ambulance officers and any other eye witnesses, before arriving at a conclusion as to the cause of death. It is the duty of the pathologist to require the production of those statements. If Colin Henry Manock had read and reviewed those statements as indicated, then he would have recorded that fact and his reasoning in relation to them. He did not do so.

Eleventh particular

In the letter to the Medical Board dated 8 May 2003 it was stated that, “There was no evidence in Ms Cheney’s medical history that she had problems with her heart.” This statement is misleading. Colin Henry Manock had not examined the deceased’s medical history before he reached his conclusion as to the cause of death of Anna Jane Cheney. If he had read and reviewed that medical history as indicated, then he would have recorded the details of it and his reasoning in relation to it, as he would be required to do in accordance with appropriate standards of proper and ethical conduct. He did not do so.

Twelfth particular

In the letter to the Medical Board dated 8 May 2003 it was stated as follows:
“There is not even an allegation as to how many tissue samples Dr Manock took. Dr Manock in fact took the standard samples for any suspicious death in these circumstances.”
These statements are misleading. At page 12 of the Second Petition there is specific reference to the number of samples Dr Manock said he took and further specific reference to what would be regarded as standard or appropriate conduct by his peers. Further particulars are contained in the affidavit of Dr Tony Thomas and the Report of Professor Douglas Henderson.

Thirteenth particular

As to bruising occurring after death, in the letter to the Medical Board dated 8 May 2003 it was stated that, “Dr Manock did consider such a possibility.” This statement is inconsistent with the evidence which he gave at the Committal of Henry Vincent Keogh. At that hearing, Colin Henry Manock stated that he “was at no time looking or thinking that the death was accidental”. If he had considered the possibility of post mortem bruising as indicated, then he would have recorded that fact and the details of his reasoning in relation to it as he would be required to do in accordance with proper and ethical conduct. He failed to do so.

Fourteenth particular

In his witness statement (autopsy report) of 29 April 1994 Colin Henry Manock stated that
“The faint bruises noted on the shins were photographed using coloured illumination and lens filters to obtain a contrast between bruised and unbruised skin.”
In his evidence at the trial of Henry Vincent Keogh he stated that the photographs of bruising which he produced to the court were taken with ordinary flash and without any special lighting. These statements are not consistent and as such are not in accordance with the appropriate standards of proper or ethical conduct of a pathologist.

Fifteenth particular

Colin Henry Manock misled the Parliament of South Australia or allowed the Parliament of South Australia to be misled in relation to the description of the importance of his evidence at the trial of Henry Keogh. The Director of Public Prosecutions informed the Court of Criminal Appeal that:
”The critical piece of medical evidence were the bruises on the lower left leg. If they were inflicted at about the time of death, that was almost the solution to the case. Because it meant that there had to be some other person present at the time of death. And the only other person it could have been was the accused.”

Earlier, the Director of Public Prosecutions had informed the jury that the
” … you might give him the benefit of the doubt, explain away in some way, the one positive indication of murder, namely the grip mark on the bottom left leg.”
Second Trial Henry Vincent Keogh Transcript p1022.

The Director of Public Prosecutions also stated to the jury:
”He [Dr Manock] takes a different view to Dr Cordner, to Dr Ansford, even to his colleague Dr James, whom the prosecution called. So be it. He was the one who saw the body, who put his hand on the marks on the lower leg and said, “That’s consistent with a grip mark and I can’t think of anything else it could be”.
Second Trial Henry Vincent Keogh Transcript p1031.

However, when the matter was subsequently reported to the South Australian Parliament the Attorney General stated that: ” Dr Manock's evidence as to how the bruises came to be on the victim's leg in the Keogh case had marginal weight and relevance to the prosecution case.” South Australian Legislative Council Thursday 20 February 2003. This was clearly incorrect.

Sixteenth particular

Colin Henry Manock misled the Parliament of South Australia or allowed the Parliament of South Australia to be misled in relation to the description of the bruises on the body of Anna Jane Cheney at the time of the trial of Henry Vincent Keogh.

Seventeenth particular

Colin Henry Manock, in making his assessments and drawing his conclusions concerning the death of Anna Jane Cheney is still, at the date of the Complaint, failing to properly consider all other reasonable hypotheses and explanations in accordance with accepted standards of proper and ethical conduct. He is also failing in his duty to give all reasonable assistance to the Medical Board in their inquiries and investigations into his work in relation to the death of Anna Jane Cheney.

Eighteenth particular

Dr Manock now knows or ought to know that his theory was and still is impossible to maintain.

Nineteenth particular

Dr Manock has failed and is still failing to properly respond to criticisms of his investigations, evaluations and failures to record pertinent information with regard to his investigations into the death of Anna Jane Cheney.

Twentieth particular

Dr Manock is and has been unable to accept proper responsibility or to engage in peer review of his work in relation to the death of Anna Jane Cheney.

Incompetence in Relation to the Practice of Medicine

First Particular

The Complainant alleges that Dr Manock is guilty of incompetence in relation to the practice of medicine. The Complainant, in addition to the following, refers to and repeats each of the particulars claimed to constitute improper and unethical conduct in relation to the practice of medicine.

Second particular

Colin Henry Manock failed at relevant times to act in accordance with the basic obligation of a pathologist, which is to consider all reasonable possibilities as to a cause of death, in relation to his inquiry into the death of Anna Jane Cheney.

At the Committal Proceedings in relation to the trial of Henry Vincent Keogh, Colin Henry Manock made the following statement:
”I was at no time looking or thinking that the death was accidental because I could find no explanation as to why she would drown.”
Transcript Committal Proceedings p 26 lines 5-8.

In the Royal Commission into Aboriginal Deaths in Custody, Counsel Assisting the Commissioner asked Colin Henry Manock that where a prisoner is found in a cell with no apparent cause of death, would he not agree that a heavy responsibility is placed on the pathologist to examine and exclude all possibilities. Colin Henry Manock replied “No I would not”.

The failure to consider all reasonable possibilities of a cause of death demonstrates incompetence and bias.

Third Particular

Colin Henry Manock failed at relevant times to act in accordance with a fundamental requirement of the practice of histopathology, namely to take adequate samples in relation to his inquiry into the death of Anna Jane Cheney.

Colin Henry Manock collected very little and in consequence there is insufficient histological material. The affidavit of Dr Tony Thomas discloses that the record does not clearly identify each of the blocks and slides of tissue which have been generated in this case. It would appear that only two blocks or slides of heart tissue, one of kidney tissue, one of lung tissue and five slides of bruising were retained in relation to his inquiry into the death of Anna Jane Cheney.

The number of tissue samples was totally inadequate for the purposes of this investigation. The failure by Colin Henry Manock to order or obtain sufficient numbers of samples demonstrates incompetence in the practice of medicine.

Fourth Particular

Colin Henry Manock failed to seek specialist advice in circumstances where the investigation into the death of Anna Jane Cheney concerned a sudden and unexplained death. Colin Henry Manock did not send either the heart or the brain for specialist examination.

In such circumstances, it was essential that the heart and brain be examined by appropriate experts.  Colin Henry Manock’s failure to have this done, in circumstances where he did not possess the relevant expertise, demonstrates incompetence in the practice of medicine.

Fifth Particular

Colin Henry Manock failed to properly weigh and measure the bodily organs. The height and weight of the body were not formally recorded. The failure to properly record these features was contrary to established pathology practices and standards. It demonstrates incompetence in the practice of medicine.

Sixth Particular

Colin Henry Manock failed to establish and maintain proper written recordings of his observations and findings. So much is demonstrated from the Major Crime running sheet where it was recorded that Dr Manock had no original notes.

The failure to make and keep proper records is contrary to established pathology procedures and standards. It demonstrates incompetence in the practice of medicine.

Seventh Particular

Colin Henry Manock failed to establish and maintain proper photographic records of the condition of the deceased and of the autopsy procedures which were said to have been undertaken.

In the course of his investigation, Colin Henry Manock took, or caused to be taken, by directions to his technical staff, black and white photographs of the body in respect of bruising where colour photographs would have been appropriate. Black and white photographs were manifestly of little utility. In addition, Colin Henry Manock misinformed the Court at the trial of Mr Keogh as to the utility of black and white photographs in respect of bruising. The judge asked Colin Henry Manock if a black and white photograph shows the bruising better and he replied that it may do so depending on the type of film used. This answer was incorrect and misleading. Second Trial Henry Vincent Keogh Transcript p154.

Failure to establish and maintain proper photographic records is contrary to established pathology procedures and standards. It demonstrates incompetence in the practice of medicine.

Eighth Particular

Colin Henry Manock developed and propounded a theory to interested and affected persons and to judicial authority as to how Henry Vincent Keogh had deliberately drowned Anna Jane Cheney when he knew or ought to have known that the theory was impossible to maintain and in so doing misled those persons and judicial authorities.  

At the Second Trial of Henry Vincent Keogh, Colin Henry Manock testified in the following terms:

If the person is sitting at the plug end of the bath and an arm is put underneath both legs to grip the left calf, either by simply lifting or lifting the leg and pushing the head, then the head could slide under the water. At this time, the edge of the bath could cause bruising to the back of the neck or the muscles attached to the base of the skull. If the movement is then continued and the legs are folded over entirely, this would have the effect of trapping the arms by the sides of the bath and the top of the head would then be against the top of the bath and that would give a flat surface that could cause the bruising to the top of the head. The left leg has been gripped. However, the right leg is merely encompassed by the arc of the arm and can move. If it thrashes around, it will bang itself against the edge of the bath and may produce bruising along the border. Transcript of Second Trial of Henry Vincent Keogh page 167 lines 6-22.

Dr Manock’s theory was based in part upon the work of Bernard Spilsbury entitled His Life and Cases (1955) which records at p 97 as follows:

Right hand on head of woman. Left forearm of assailant beneath both knees. Left forearm of assailant raised suddenly while right hand is pressed on head of woman. Then the trunk of the body slides down towards foot end of bath, the head being submerged in water.

The Director of Public Prosecutions in his address to the jury during the course of the Second Trial of Henry Vincent Keogh relied upon and emphasised the significance of the theory and invited the court and the jury to rely upon it.  

In giving expression to the theory, during the course of the Second Trial of Henry Vincent Keogh, Colin Henry Manock stated that “The left leg has been gripped”. The grip mark is essential to the theory. If the evidence available to Colin Henry Manock does not establish the existence of a grip mark on the left leg of Anna Jane Cheney in a manner conformable with the assumption which formed part of the theory, then the theory cannot be substantiated.

The evidence of Dr Ross James and the evidence of Professor Stephen Cordner given during the Second Trial of Henry Vincent Keogh failed to support the evidence of Colin Henry Manock in relation to this matter.

In his evidence at the Second Trial of Henry Vincent Keogh, Colin Henry Manock stated that the various bruise marks were caused at or about the same time and that their configuration meant that they were a grip mark and that he couldn’t think of anything else that they could be. This demonstrated incompetence in the practice of medicine.

It was an essential part of Colin Henry Manock’s theory that there was a thumb bruise on the inner or medial side of the left leg of the deceased. The only evidence to support the existence of the bruise at the time of the Second Trial was the recollection of Colin Henry Manock supported by photographs and histology slides which are now revealed to be manifestly inadequate.

If that bruise does not exist or cannot be established then there is no proof of a grip. It was Colin Henry Manock and only Colin Henry Manock who said that he saw a bruise on the inner left leg. Given the deficiencies which have now been revealed in relation to the photographs and the histology slides, the evidence of Colin Henry Manock remains the only evidence to support the existence of that bruise. Dr Manock’s failure to obtain proper evidence to support his observations amounts to incompetence in the practice of medicine.

In his autopsy report of 29 April 1994 in relation to the death of Anna Jane Cheney, Colin Henry Manock stated that the bruises which he had observed on the body had been caused close to the time of death. This includes the period both shortly before and shortly after the death. Even if the thumb bruise was a bruise, it could have occurred as a result of people handling the body after death. Such people could have included Henry Vincent Keogh, the ambulance officers and the police officers. On this basis alone, it is not possible to maintain that the theory relates exclusively to the actions of Henry Vincent Keogh. Dr Manock’s failure to properly consider this matter amounts to incompetence in the practice of medicine.

Associate Professor Tony Thomas is an expert in histology. He has examined the slide said to have been taken from the medial side of the left leg of Anna Jane Cheney. He states that the histology does not support the claim that this mark is a bruise.  

Associate Professor Gale Spring is an expert in forensic photography. He has examined the photographs said to be of the mark on the medial side of the left leg of Anna Jane Cheney. He states that the photography does not support the claim that this mark is a bruise.

It can be demonstrated, with the use of the computerised graphics, that the arrangement of the marks, as they were said to exist on the left leg of Anna Jane Cheney, would in any event be inconsistent with the theory as they are not consistent with the use by an assailant of a left hand grip or of a right hand grip.

Professor Maciej Henneberg is an acknowledged expert in functional anatomy. He has confirmed that the theory developed and propounded by Colin Henry Manock in relation to the death of Anna Jane Cheney is not consistent with the established knowledge of functional anatomy.

In developing and propounding his theory Colin Henry Manock referred to something which he described as the “flotation effect”. He said that it was his opinion that the exposed parts of the body would be weightless and would float in water. This opinion is incorrect and is not supported by his peers. Professor Maciej Henneberg has stated in his evidence that the floatation effect is irrelevant as the body would be resting on the bottom of the bath.

Ninth particular

The opinion of Colin Henry Manock that the death could not have resulted from accidental causes demonstrates incompetence in the practice of medicine. He should have investigated and evaluated all reasonable explanations as to the cause of death which were consistent with the available physical evidence. He should have fully recorded the nature of those investigations and his reasoning in relation to them. He failed to do so. His conclusion as to the cause of death of Anna Jane Cheney goes beyond reasonable interpretations of the available physical evidence and is not supported by his peers.

Professors Cordner, Ansford, Thomas and Pounder and Dr Collins, in their evidence will confirm that the circumstantial evidence in relation to the death of Anna Jane Cheney is consistent with a conclusion of death by accidental means.

Tenth particular

The opinion of Colin Henry Manock that the death could not have resulted from natural causes demonstrates incompetence in the practice of medicine. He should have investigated and evaluated all reasonable explanations as to the cause of death which were consistent with the available physical evidence. He should have fully recorded the nature of those investigations and his reasoning in relation to them. He failed to do so. His conclusion as to the cause of death of Anna Jane Cheney goes beyond reasonable interpretations of the available physical evidence and is not supported by his peers.

Professors Cordner, Ansford, Thomas and Pounder, and Dr Collins in their evidence will confirm that the circumstantial evidence in relation to the death of Anna Jane Cheney is consistent with a conclusion of death by natural causes.

Eleventh particular

The opinion of Colin Henry Manock that the death could not have resulted from anaphylaxis demonstrates incompetence in the practice of medicine. He should have investigated and evaluated all reasonable explanations as to the cause of death which were consistent with the available physical evidence. He should have fully recorded the nature of those investigations and his reasoning in relation to them. He failed to do so. His conclusion as to the cause of death of Anna Jane Cheney goes beyond reasonable interpretations of the available physical evidence and is not supported by his peers.

Professor Malcolm Fisher is an acknowledged expert in emergency medicine and anaphylactic reactions. In his evidence he confirms that in the investigation of a sudden and otherwise unexplained death of an adult, it would have been mandatory to investigate and consider anaphylaxis as a possible cause of death. If such an investigation had been undertaken, Colin Henry Manock would have recorded the nature of those investigations and his reasoning in relation to them. He failed to do so. His conclusion as to the cause of death of Anna Jane Cheney goes beyond reasonable interpretations of the available physical evidence and is not supported by his peers.

Twelfth particular

In his witness statement (autopsy report) of 29 April 1994 Colin Henry Manock stated as follows:
”On 22 / 3 / 94 I returned to the mortuary and re-examined the scalp. I reflected the scalp as far as the attachment of the neck muscles and this revealed 2 oval bruises 2 cm x 1 cm.”
This was the second day after the initial refection of the scalp. This was performed incompetently. There was no reason why the complete reflection of the scalp could not have been undertaken at the first autopsy examination.

Colin Henry Manock failed to properly investigate, evaluate and rule out artifactual explanations for the marks which he said he found subsequent to his second reflection of the scalp during his investigation into the cause of death of Anna Jane Cheney. If such an investigation had been undertaken, Colin Henry Manock would have recorded the nature of those investigations and his reasoning in relation to them. He failed to do so. His conclusion as to the cause of death of Anna Jane Cheney goes beyond reasonable interpretations of the available physical evidence and is not supported by his peers.

Thirteenth particular

In his investigation into the death of Anna Jane Cheney, Colin Henry Manock failed to properly investigate and evaluate the significance of the medical history of the deceased and the photographs of the deceased taken at the scene on the night of 18 March 1994. If such an investigation had been undertaken, Colin Henry Manock would have recorded the nature of those investigations and his reasoning in relation to them. He failed to do so. His conclusion as to the cause of death of Anna Jane Cheney goes beyond reasonable interpretations of the available physical evidence and is not supported by his peers.

Particulars of lodgement

This Amended Complaint is lodged by

of

in the State of South Australia,

the solicitors for the Complainant Henry Vincent Keogh

DATED 18 November 2004

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