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A state of Injustice - Dr Robert N Moles
Chapter Nine - ‘There being nothing suspicious …’

A state of Injustice: table of contents

Also by Dr Moles - Losing Their Grip - The Case of Henry Keogh - Definition and Rule in Legal Theory

Terry Akritidis 1990 - Peter Marshall 1992

The Akritidis and Marshall cases are discussed together as they are examples of the problems that arise when a death is considered ‘not suspicious’ and the scene treated within guidelines and the autopsy is not performed until the following day. In the case of Marshall, it meant that the examination of the scene was compromised because the cause of death given to the police by the pathologist attending at the scene, Dr Manock, was wrong. In the case of Akritidis, the police did not properly examine the scene or call a pathologist to it. It turned into a classic case of ‘tunnel vision’ created by assumptions.

Terry Akritidis

Elefterios (Terry) Akritidis was a ‘troubled’ person, and had been in psychiatric care spasmodically. [1] On occasions he could be verbally and physically violent. Even his parents had taken out a restraining order against him. More recently, he had turned up at the police social club and thrown a glass into the assembled throng. He was convicted of assault and sentenced to a short period of imprisonment.

He had been out of prison for a short while, and was staying at a hostel for recently released prisoners on the coast just outside Adelaide. He was quiet and withdrawn. He spent some days working with staff and inmates from the hostel on the refurbishing of a local hall. The staff thought well of him. ‘You could tell he came from a good home,’ the manager said.

His death

Akritidis’s body was found late on the evening of 3 August 1987 in a fairly remote location near Yankalilla, about 65 kilometres south of Adelaide. The local milkman later said that he had seen him behaving oddly on the road in the early morning of the day on which Akritidis died. At times it appeared that he was marching along with eyes straight ahead. Some suggested that this had to do with his interest in joining the Greek army. The milkman said that Akritidis was walking along the line in the centre of the road and on occasions moved in front of his truck, making it difficult for him to get by. The milkman went back to the local shop to phone the police who came along and, as one of them said in his statement, ‘conned’ Akritidis into going back to the station with them.

According to the police account, Akritidis was with them from 5 am and left the station at around 7.30 am that day. The police had spoken with his parents on the phone. They could see no basis on which to arrest or detain him and said they were unaware of his previous mental problems. They had offered him money and had offered to cook breakfast for him, both of which he refused. He did however take a couple of slices of bread with him and wandered off down the road in the direction of Adelaide.

Later that day, the police said that some defect had been reported in the police radio equipment which was associated with the communications tower on a hill (appropriately named Mount Terrible) just outside Yankalilla. Police technicians were despatched to the tower and at about 6 pm they reported finding the body of a young man on the ground near to the tower. The technicians called their police colleagues to the scene. By the time they arrived it was getting dark, wet and quite cold. The tower was at a remote location at the top of the hill that could only be reached in a four-wheel-drive vehicle, and then only with some considerable difficulty. The police officers noticed that there was a hole in the roof of the hut beside where Akritidis was lying and they presumed that he had jumped off the tower, hit the roof and then landed on the ground. It was determined that there were no suspicious circumstances and Akritidis’s body was put into the back of the police vehicle. A few stones were used to mark where his body lay, and his body was taken to the mortuary in Adelaide. Because the death was deemed non-suspicious it was not examined there until the next day.

The police officers said that they did not to collect any forensic evidence that evening because nothing was going to be done that night to ‘further contaminate the scene’. However, they did acknowledge that it was quite windy and raining slightly at the time. Relevant evidence, especially blood or other materials or stains, could either have been blown or washed away during the night.

There are no photographs of the scene that night. The police reported that they were unable to take any photographs because, even though a police photographer had attended the scene, he did not have some part of his equipment and was unable to take a picture with a flash light.

The Inquest

It was not until 1990, some three years later, as a result of persistent lobbying by Akritidis’s father, that a coroner’s inquest was arranged. It was only at this time that the witness statements were taken and the autopsy report became available. The inquest was undertaken by a senior magistrate in Adelaide, as Deputy State Coroner.

Witnesses’ observations

One farmer said that a person he presumed to be Akritidis had come into his shed as he was getting hay and asked if he could go and look at some rocks at the quarry. This farmer did have a quarry on his land, but we have no way of knowing how Akritidis knew about it. The farmer said that Akritidis climbed through the electrified fence without so much as flinching, even though the fence would give 'a fair sort of a kick'. He then walked off in the direction of the quarry.

Another man said that he saw a person he presumed to be Akritidis coming out of a field and through a fence onto the road. He only got a quick glance at him as he drove by, but thought that it must have been him as they didn’t often get people just wandering about the countryside without there being a car or other people nearby. It appeared that if the witnesses’ observations were correct, Akritidis had walked about 70 kilometres in the twenty-four hours prior to his death. An ‘extraordinary feat’ for a person in his condition, said the psychiatrist in giving evidence. Bear in mind, though, the earlier discussion about the unreliability of eye-witness evidence, and the fact that these events were being recalled some three years later.

Pathology evidence

Dr Manock gave evidence at the inquest in place of a Dr Ashby who conducted the autopsy on Akritidis but who was no longer working in South Australia. [2] Her report showed that he had sustained significant internal injuries, the main one being a ruptured aorta, the main blood vessel leading from the heart. He also had significant fractures to both arms and to his ribs. His sternum was lacerated and he had some minor damage to the lungs. The report concluded that Akritidis had died of ‘multiple injuries’ and commented that the injuries were ‘consistent with a fall from a very considerable height’.

It was thought that Akritidis had committed suicide: it seemed that he had climbed through the barbed wire and up through the security hatch at the bottom of the tower which had been inadvertently left unlocked. Even though it was a police communications tower, nobody was able to determine who had last accessed it and left the hatch unlocked. It was suggested that Akritidis had jumped off the tower, landed on the concrete roof of the building adjacent to the tower, and then bounced off that onto the ground.

It was said that Akritidis’s body struck the concrete roof of the building with such force that it broke through the concrete, which was 5 cm thick, and caused some of it to fall into the building. The concrete was reinforced with 4-mm thick steel rods which ran through the concrete in a grid pattern 75 mm apart. It was said that the rods were bent inwards with the force of the blow.

Although Akritidis was said to have been falling ‘partially inverted’, there was little damage to his head and, as Dr Manock stated in his evidence, there were no ‘significant’ external injuries. There were no signs of bleeding when his body was found. The fact that Akritidis’s body was lying there on the ground, and there was a hole in the roof of the hut, was enough for people to conclude that Akritidis had damaged the roof when falling onto it ‘from a considerable height’.

When bodies and concrete collide, the normal expectation is that the body will come off worst. It is unfortunate that no one thought to seek an opinion from someone who would know about these things, such as an engineer. Dr Manock couldn’t be thought to be an expert in this area. At least he produced no evidence at the hearing to that effect.

Police procedures

The police forensic procedures state that where there is a sudden or unexplained death, the scene must be treated as a crime scene and cordoned off until after the scene has been properly examined. That was not done. Crime scene examiners would have examined the ground leading to and from the tower to determine if there were any footprints or any tyre marks in the vicinity. The ground was wet at the time, and it would have been relatively simple to determine if Akritidis’s footprints were there – and if they were, whether they were the only set in the vicinity of the tower that day. If he had died elsewhere, for example, and his body placed at the scene, then obviously there would have been other prints and perhaps vehicle tyre marks as well.

Akritidis’s body was fully, although quite lightly, clothed when found. He had been wearing what some said was a flannel shirt, and others described as a western style shirt, with denim jeans. Without removing his clothing the police could not determine the full extent of the injuries. The police who first attended at the scene were (on their own admission) inexperienced in crime scene examinations. They would not have been able to gauge the likelihood of a body ‘bouncing’ off the roof and onto the ground.

There was no forensic examination of the roof to determine whether there were traces of blood, tissue or clothing to indicate whether Akritidis had in fact caused that damage. One police officer said that he had examined Akritidis’s body and, on lifting his shirt, he noticed some grazing to his back which had a white powdery material on it similar to the concrete of the roof. It appears that no samples were taken of this powder. If it was in fact concrete powder from the roof, then it is difficult to explain how that material was on Akritidis’s back rather than the outside of his shirt. Unfortunately, Akritidis’s clothes were  destroyed within a few days of the autopsy.

The tower was not examined by crime scene examiners to determine whether Akritidis’s footprints were on the steps of the ladder going up the inside of the tower, or on the cross bars of the tower itself. If he had climbed the tower, his muddy footprints would most likely have been found on the steps, and his fingerprints on the uprights. No evidence was produced to this effect. The ladder steps up the tower were thin metal rungs. Having climbed some 100 of them there would be little mud left on Akritidis’s shoes, especially on the soles of his shoes, which were smooth. Yet the soles were still ‘liberally coated with mud’ at the time of the autopsy, according to the report.

An examination of that mud would have indicated whether it had come from the area in the vicinity of the tower or from elsewhere. That might indicate where Akritidis had died. No such evidence was given at the coronial hearing.

Neither the Deputy Coroner, nor the counsel representing Akritidis’s family, asked why these and other investigations had not been carried out. No one asked why crime scene examiners had not been called to the scene.

Explanations to the inquest

Dr Manock reviewed the autopsy notes and then provided explanations to the inquest for most of what they contained. An expert witness is required to be well read in their area of expertise. Dr Manock was asked if he had done some reading about the severity of injuries sustained following falls from particular heights. Dr Manock said that he had. The Deputy Coroner followed this up by asking him, ‘Is there a body of material that’s directed at that topic of endeavour?’ He replied: ‘I’ve been going back through some of my old post-mortem reports where people have jumped from car parks and the like …’

An expert witness would normally refer to textbooks and to peer-reviewed papers published in the medical and scientific literature. [3] But the Deputy Coroner did not press the topic.

Counsel for Akritidis’s family asked Dr Manock if it was normal for there to be no external injuries on the surface of the body when it was said that it had broken through such thick reinforced concrete.

Dr Manock said, ‘I wish I knew what the height was and I could estimate the speed. Are we talking about 140 feet [42.7 metres] or 200 feet [61 metres] or 400 feet[122 metres]?’ The Deputy Coroner then pointed out that the height of the tower was 47 metres or 150 feet, therefore the maximum possible fall could be no more than that.

Dr Manock said that in that case, the velocity at impact would be approximately ‘100 feet per second’ (about 30 metres per second, which is about 100 kilometres per hour) – about the same as being in a moderate speed head-on car crash, he explained – except that Akritidis would not have the protection of a vehicle around him. He went on to say that there were no significant external injuries and he did not find that unusual. He said the breadth of the shoulders would have taken the major impact.

The Deputy Coroner asked Dr Manock if an impact with a hard surface would leave some abrasions or cuts of the type and nature seen on Akritidis’s body. Dr Manock replied that clothing, coming between the skin and the surface that the body strikes, would affect the production of abrasions and that there may be only minor marks if the clothing is relatively thick.

Yet it was an accepted part of the evidence in this case that Akritidis was wearing just a light shirt and jeans at the time of his death. His jumper was  neatly folded and left on a fence that led into the field where the tower was.

Dr Manock told the Deputy Coroner that, from his reading of his old autopsy reports, Akritidis’s injuries were precisely the sort of injury pattern that one would see, particularly if the person lands on the shoulders or the centre of the back. He said that the fracture of the spine at the level of the T3 and T4 vertebrae (the vertebrae near the top of the back, a little below the neck) is a classic injury of impact of the shoulders while the body is partially inverted after a fall from some considerable height. It is hard to think, though, that the shoulders could strike the concrete pad with such force without the head striking it at the same time. Yet there were no fractures to the skull.

The pathologist who conducted the autopsy had noted that there was ‘scattered bruising’ of the scalp. She said that there were no fractures of the vault (the main part of the skull) or the base of the skull. The meninges (the membrane surrounding the brain) and the brain were also normal. The aorta, however, ‘showed a traumatic rupture at its isthmus’. This type of injury is seen in sudden stopping, such as in car accidents where the chest is compressed against the steering wheel and the heart is forced downwards. If Akritidis was falling head down as is suggested, one would have thought that his heart would have been forced effectively upwards within his body.

Dr Manock was asked by the Deputy Coroner, ‘was the rupture of the aorta the immediate cause of death?’ Dr Manock said that it was. He then went on to say that it means that the blood pressure in peripheral tissues also drops very rapidly, so there is unlikely to be external bleeding as there is no effective blood pressure to cause such bleeding. However, bleeding will occur at autopsy when the heart has stopped beating, so the comment about blood pressure does not adequately explain the lack of bleeding. If any collision were to cause damage to the tissues sufficient to cut across any of the blood vessels, then there would be bleeding – torn aorta or no torn aorta – provided that there is still fluid blood within the vessels.

As well as no photographs being taken at the scene, no photographs were taken of the body at the autopsy. Dr Manock said that in 1987 it probably wouldn’t have been usual to take photographs at an autopsy. He said that in any event this autopsy was started at 8.15 am, and the photographer normally arrived at 8.30 am. It seems no one thought to start the autopsy fifteen minutes later, or to ask the photographer to get in fifteen minutes earlier.

The autopsy report had stated that death ‘might have taken place about 12 hours before discovery’ – that is, before the body was found. This would put the time of death at about 6 am on 3 August. We now know that at that time Akritidis was in the custody of the police at the Yankalilla police station.

Counsel for the Akritidis family asked Dr Manock to comment on the statement that death might have taken place 12 hours before discovery. Dr Manock said that he thought the word ‘discovery’ was in error. He said that he didn’t think the word should appear there at all. He thought it to be ‘more reasonable’ to him that it should have been 12 hours before the body was undressed at the autopsy the following day. According to this explanation, Akritidis would then have died around 8.15 pm the previous evening. However, that time would have been some two hours after the police discovered his body.

Counsel asked Dr Manock about the range of accuracy in which he was able to determine a time of death. He said that in the circumstances of this case, accuracy was ‘out of the window’. He explained that the pathologist has very little chance unless they are called to the scene of the death and take body temperatures. He said that from the wrinkling of the feet due to contact with water, one may be able to say ‘12 hours, 24 hours, 36, a week, something of that order’.

Dr Manock was then asked if he thought Dr Ashby had made her calculation simply from the appearance of the feet, and he replied: ‘Yes, she certainly took no temperatures, so she hasn’t got a more scientific basis on which to judge time of death’.

There are, however, many ways in which time of death can be estimated. The processes of lividity and rigor mortis can be helpful indicators within the first 48 hours.

Dr Manock went on to suggest that lividity would be ‘non-existent’ because of the torn aorta. This is not correct. When a person dies, the blood gradually moves through the blood vessels and, under the force of gravity, it settles at the lowest part of the body. Thus the lowest part of the body will go pink and then purple in colour as the lividity progresses. To suggest that this process would be halted because of the torn aorta is wrong. A rupture of the aorta at the aortic arch would mean that some blood could be pumped out before the heart stops. Some more blood might escape from the opening after death. However, a considerable amount of blood will remain within the blood vessels and will still settle at the lowest part of the body. Akritidis’s body would have had about 4 litres of blood left within the system of blood vessels, given that Dr Ashby stated in her autopsy report that she had found 'approxiamately 1 pint' [about half a litre] of blood within the chest cavity.

The police at the scene acknowledged that Akritidis’s body was cold and stiff when they found it, which means that he had in fact been dead for some time. We know that it was very cold on the mountain that day. The cold would slow down the rate of the development of rigor. This would tend to support the pathologist’s view that Akritidis had been dead for some time before his body was found. The police could not have seen the pattern of lividity because the body was clothed. If that pattern had been confirmed by photographs at autopsy, then it would do much to reveal the position of Akritidis’s body when he died. Without those photographs, and without any observations in relation to the pattern of lividity, we have to say that the record and procedures are seriously deficient.

For Dr Manock to observe that the pathologist had not made any comment about relating rigor mortis to the time of death, and the acceptance that it may not have been considered by her, should have given rise to questions.

Failure to follow guidelines

Akritidis’s death was sudden, violent and unnatural, and no qualified medical practitioner was available to issue a death certificate. Therefore, the cause of death had to be established by a pathologist. In South Australia, General Order 8278 clearly instructs operational police that they must treat every unexplained death as a homicide to make sure that no vital evidence is lost. This rule was not followed.

The forensic procedures state that the scene in every such case is to be treated as if it were a crime scene. The scene must be cordoned off, access to it must be controlled and all evidence collected. This includes posting a guard to control access and to record details of all the people there. Yet the deputy Coroner had some difficulty in establishing the identity of a painter who was said to have turned up to the scene and then left. It seems that no one had bothered to record his details at the time. It might also have been expected that in addition to photographs, footprints and fingerprints would have been recorded. Nowhere in the procedures does it say that the first officer on the scene can ignore the directions of the established procedures if the answer ‘appears to be obvious’. Indeed, the procedures actually state that especially where the answer appears to be obvious, one must look carefully to ensure that all of the facts are consistent with the assumption of what appears to be ‘obvious’.

Failure of documentation

The pathologist had not filled in a body chart in her case notes. Dr Manock said that it was his view that it was ‘not unusual’. The standard body chart is pre-printed with an outline of a person, and the pathologist merely has to to indicate on the diagram where injuries or marks are found. Dr Manock told the Deputy Coroner that the completion of such a document was ‘a matter of choice’ for each pathologist and that it was his view that it was 'not unusual' to fill one in. He said that he preferred to ‘rely on descriptions’ as he had not any ‘artistic ability’, and he shied away from drawing charts and diagrams.

Deputy Coroner’s finding

On 22 June 1990, the Deputy Coroner handed down his findings in this case. The Deputy Coroner determined that Akritidis had taken his own life by climbing the tower and then falling to his death. While the Deputy Coroner commented that the evidence Dr Manock gave to the inquest was of considerable assistance, he was critical of the autopsy. The Deputy Coroner wrote:

"I am somewhat critical of the procedure that was adopted at autopsy. In my view, it is likely that assumptions were made at the outset that the deceased had taken his own life. Ultimately I think that that assessment was correct however, in my view, that clouded the empirical taking of observations at autopsy.” [Emphasis added]

Peter Marshall 1992

The police found Peter Marshall, 35, lying dead in his home unit. He was next to his bed with blood was pooling around his head. Dr Manock attended at the scene and concluded that Marshall had died by falling out of bed and hitting his head. 'There being nothing suspicious' everyone went home and Marshall's body was taken to the mortuary where nothing further was done until the following day.

During the autopsy, however, a bullet hole was found in Marshall’s head, and a bullet was found lodged in his brain. The Forensic Science Centre said that the standard practice in South Australia was 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. [4]

Endnotes

1. The information on this case is taken from the transcript of evidence before the Coronial Inquest which commenced on 23 April 1990, and the Finding of Inquest concerning the death of Elefterios Akritidis, 22 June 1990.

2. The pathology information is taken from the Forensic Science Centre autopsy report dated 7 August 1987; and from the transcript of Dr Manock’s evidence to the Coronial Inquest.

3. Such as, for example, UKDA Goonetilleke, ‘Injuries caused by falls from heights’, Medicine, Science and the Law, no. 20, 1980, pp. 262–75.

4. ‘Intruder theory in shooting and bungle over shooting victim’, The Advertiser, 7 February 1992.

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