A state of Injustice - - Dr Robert N Moles

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Chapter Eight - No clothes, no files, no suspicions

John Highfold 1983
Kingsley Dixon 1987

The Highfold and Dixon cases are similar – both cases involved the death of a prisoner and in both cases their clothing went missing and could not be examined. Both cases were the subject of a coroner’s inquest and subsequently were among the first cases dealt with by the Royal Commission into Aboriginal Deaths in Custody held between 1987 and 1989.

John Highfold

John Highfold, 30, was an Aboriginal man who was found dead in his cell at Adelaide Gaol on 4 January 1983. [1] He was known to be epileptic and was being treated for it by medication. The pathologist, Dr Manock, commenced the autopsy within two and a half hours of the death and determined that the cause of death was massive oedema in the lungs as a result of ‘status epilepticus’. An inquest was held just four days later and the Coroner, Mr Ahern, found that Highfold died from ‘natural causes’.

At the hearing of the Royal Commission into Aboriginal Deaths in Custody, the Senior Director of Neurology at Flinders Medical Centre in Adelaide, who was a specialist on epilepsy, said that there was no test which could establish epilepsy as a cause of death. He said it was ‘circumstantial’ to conclude that Highfold had died from a seizure. He said it was quite possible that Highfold had not died from epilepsy as found by the Coroner – he had never seen anyone die from a single epileptic seizure. He said that all the major organs should have been examined and the blood should have been tested for drugs, especially Dilantin, which was being used to treat Highfold’s epilepsy. [2] Dr Manock, he said, did not do that. Another doctor said that Highfold’s prison medical file ‘appeared to have been lost’.  There was no record of it being passed to the Coroner and it was therefore doubtful if it was seen by the pathologist. [3] His clothing had also ‘gone missing’ and therefore it couldn’t be examined.

Dr Manock told the Royal Commission that cost had been a factor in deciding not to undertake the blood tests. He said that at the time of the autopsy full toxicological testing could have cost $2000. When asked if testing would have revealed any poisoning, Dr Manock said that he didn’t do the test as Highfold didn’t have access to poison. Counsel assisting the commission told Dr Manock that this was an assumption. Testing could, however, have ruled out the possibility that Highfold had taken any drugs or that they could have been administered to him by others.

Dr Manock said that because Highfold’s stomach was empty, a drug overdose was unlikely. However, there are many mechanisms by which drugs can get into someone’s system. Absorption through the stomach is only one of them. Dr Manock was asked why he had not tested the level of Dilantin in the blood as the level found might help to determine if he was being properly looked after. Dr Manock said that the presence of Dilantin would not necessarily prevent a seizure, although the risk of death would have been greater without it. He said that cost was a factor here as well – $18.40 in 1983. [4]

Counsel assisting the commission said that by regarding Highfold’s death as routine, Dr Manock’s approach had been ‘inappropriate’ as part of vital investigations into a death in custody. Counsel asked Dr Manock if he began the autopsy assuming the conclusion was to be death from epilepsy. Dr Manock said he would start every autopsy ‘with an open mind’. In his report, Dr Byron Collins, a consultant pathologist retained by the lawyers for Highfold’s family to evaluate Dr Manock’s work, criticised the lack of thoroughness of the autopsy, saying that the only major organ that had been checked microscopically was the brain. Dr Manock claimed in court, however, that he had microscopically examined the heart and lungs as well. He produced microscope slides from his pocket to show that he had done this, even though heart and lung histology was not noted in his report. [5] Dr Collins told the Commissioner that a single section of the heart was insufficient to exclude heart disease as a cause of death. [6]

Dr Collins said that the autopsy report did not canvass all possibilities. There was no toxicological analysis of the blood, which should have been examined for both alcohol and drugs.

Counsel assisting the commission asked Dr 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? Dr Manock replied, ‘No I would not’.

He 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’. [7]

Assisting counsel said the Coroner must be criticised for not ensuring ‘more rigorous scrutiny’ of Highfold’s death. No photographs were taken of his cell, his clothing was not retained and a torn shirt collar attracted no suspicion. This was not examined, nor was a damp patch that was noted to be on his pillow. The police investigations had been ‘quite inadequate’, the assisting counsel said. Counsel told the Commissioner that it was ‘unfortunate’ that the Coroner’s inquiry had relied on written statements only. [8]

The lawyer for Highfold’s family said that the deceased had been buried in a pauper’s grave because the family had not been notified. A police officer agreed that his running sheets showed that no attempt had been made to contact Highfold’s South Australian relatives. He agreed that, as the first police officer on the scene, he had a responsibility to investigate the death. He said that he did not, however, seize Highfold’s clothing for examination. On the day Highfold died, he had only interviewed one person, another inmate. He did not seek to examine a stain on the pillow or the collar torn from his shirt, and did not receive, or seek to obtain, a copy of the autopsy report. ‘I never saw the body at all,’ he said. ‘To me it seemed to be a simple death in custody. I didn’t see anything at all at the time to indicate that it was a death of a suspicious nature.’ [9]

The Royal Commissioner’s finding

When the Royal Commissioner released his findings he was critical of both Dr Manock and the Coroner, Mr Ahern. He said that the Coroner’s investigations had not been thorough and that Highfold’s family had not been made aware of their right to be present at the inquiry.

He said that Dr Manock had regarded the autopsy as ‘routine’ once it was concluded that the death was not suspicious. He had ‘relied perhaps too far on assumptions that had not been satisfactorily proven’ and had not made all relevant investigations. The administration of poisons or drugs could not be excluded as a cause of death because no toxicological analyses were performed. He said that the more likely cause was heart failure due to a sudden change of heart rhythm (arrhythmia) which could have resulted from a single epileptic fit. He said that it was probable that Dr Manock’s opinion as to the cause of death (status epilepticus) was incorrect. [10]

Kingsley Dixon

Kingsley Dixon was a 19–year-old Aboriginal man who was said to have been found dead in his cell in Adelaide Gaol on 9 July 1987. [11] Dr Manock performed an autopsy the next day and concluded that Dixon’s death had resulted from asphyxiation due to hanging.

Dixon had a slight bruise on his head. Dr Manock said that this was consistent with his having struck his head against the cell wall while hanging. He also said that there was no injury which could not be explained by the ‘mechanism of hanging’.

The Royal Commission into Aboriginal Deaths in Custody was told that Dixon’s clothes had ‘disappeared’ after being removed from his body – just as Highfold’s clothes had gone missing in 1983. [12]

Concerning the autopsy, the Commissioner noted in his report: ‘Comprehensive colour photographs were taken during the autopsy procedures which enable me to accept Dr Manock’s findings – particularly as to bruising or lack of bruising.’ [13]

This contrasts with the situation in the Keogh discussed in Chapters 11 and 12.

The Commissioner also remarked that an issue had arisen over a request by Dixon’s family to delay the initial autopsy until an independent pathologist could be present – a request that had been denied. He concluded: ‘Whilst no doubt the presence of an independently appointed pathologist may be desired and may be of comfort to relatives, the critical importance of an early autopsy cannot be over-emphasised.’ [14]

This is a most interesting remark. It downplays the value of the presence of a second pathologist, in contrast to the principle of independent checking of observations promoted by Judge Shannon in the Splatt Royal Commission some four years earlier. Such independent corroboration would have been of assistance in the autopsies in the ‘Baby Deaths’ cases (discussed in Chapter 10) and in the Keogh case, for example. The emphasis on the importance of an early autopsy is worth noting in the context of the Akritidis case, the Marshall case and even the Keogh case, all of which we are about to discuss.

Endnotes

1. Royal Commission into Aboriginal Deaths in Custody: Report of the Inquiry into the death of John Highfold, 25 January 1989, (JH Muirhead, Commissioner).

2. The Advertiser, 19 April 1988.

3. Ibid.

4. See Royal Commission Report (Highfold), at 8.3.

5. Ibid. See also The Advertiser, 20 April and 21 April 1988.

6. See Royal Commission Report (Highfold), at 8.3.

7. The Advertiser, 21 April 1988.

8. The Advertiser, 16 August 1988. See also Royal Commission into Aboriginal Deaths in Custody, Report (Highfold), ref. 1, at 8.1.

9. The Advertiser, 15 April 1988.

10. See Royal Commission Report (Highfold), at 8.3.

11. Royal Commission into Aboriginal Deaths in Custody: Report of the Inquiry into the death of Kingsley Dixon, 2 February 1989, (JH Muirhead, Commissioner).

The Advertiser, 30 September 1987, 19 February 1988 and 3 February 1989.

12. The Advertiser, 15 April 1988.

13. See Royal Commission Report (Kingsley Dixon), at 5.1.

14. Ibid.

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