A state of Injustice - - Dr Robert N Moles

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Chapter Ten - Seeing things - The Baby Deaths Inquest, 1994

Between 1994 and 1995, the Coroner in Adelaide held an inquest into the deaths of three babies who had died suddenly in separate incidents. The babies were: Storm Don Deane, aged 3 months, who died on 16 October 1992 at the Adelaide Children’s Hospital; William (Billy) Barnard, aged 9 months, who died on 31 July 1993 at the Adelaide Children’s Hospital; and Joshua Clive Nottle, aged 9 months, who died on 17 August 1993 at the Modbury Hospital, Adelaide.

In each case Dr Manock had conducted the autopsy. The cause of death for each was given as bronchopneumonia, a basic lung infection, associated with other features.

In Storm Deane’s case a congenital heart defect was also referred to. In Billy Barnard’s case bone fractures of the right arm were also referred to. In Joshua Nottle’s case it was noted that there were also multiple rib fractures. The police and the doctors involved thought causes of death given by Dr Manock weren’t correct, and may have concealed serious child abuse, or even homicide.

The police made their views known to the Coroner, Mr Wayne Chivell, who decided to hold an inquest into all three deaths. He commissioned Dr Tony Thomas as an independent pathologist to review and assess Dr Manock’s autopsies. The following discussion is based on the Coroner’s findings, the transcript of evidence before the Coroner, the report of Dr Tony Thomas that was accepted by the Coroner, Dr Manock’s autopsy reports in each of the three deaths, and the ABC TV 4 Corners program. ‘Expert Witness’ [1]

Storm Deane

Storm was born on 18 July 1992 to Craig and Heather. He lived with his parents and three siblings who were aged ten, six and four. Craig stayed at home to look after the children, and Heather worked as a telemarketer. Craig said that on Thursday 15 October 1992, while he and Heather were at home, he took Storm from the baby bouncer by grabbing hold of the front of his jumpsuit without supporting his head. Craig described taking him to the master bedroom: ‘I picked him up by the scruff of his clothes and carried him like a little carrying bag … I flipped him, and he went about two feet forward and then landed on the bed.’ [2]

Craig told the doctors at the time that he had flipped all his children in this manner, throwing them through the air onto the bed. He had the belief that this taught the babies how to fall properly and would be helpful during their later life. In an effort to show them how to breathe from the diaphragm rather than from the chest, he had squeezed the baby around the chest on various occasions. [3]

After putting Storm on the bed, he and Heather went outside to fix his Harley Davidson motor bike. Heather later went to check on Storm and found him looking pale and not moving. Craig tried mouth-to-mouth resuscitation, but without success. Heather called an ambulance.

When the ambulance arrived, Craig was said to have run out of the house with the baby and to have fallen over. However Storm didn’t hit the ground. The ambulance officers connected Storm to an electrocardiograph to measure his heart activity. They said that he was cold and grey, he had no heartbeat and he wasn’t breathing. He was rushed to the Lyell McEwin hospital and then from there to the Adelaide Children’s Hospital. The following morning it was agreed that Storm’s life support would be terminated and Storm was pronounced dead. One of the doctors reported that at the time the life support was terminated, Craig had placed his thumb on the baby’s throat saying that he did not like to see him gasping. The doctor said that while he was disturbed by this action it did not (in his view) contribute to the baby's death.

After having regarded Craig’s unusual behaviour, two doctors at the hospital expressed concerns about the cause of death. The consultant paediatric pathologist at the hospital arranged for a full examination. This revealed that there was extensive bruising, a skill fracture and rib fractures, and an ulcer on the right buttock.

Storm’s body was sent to the Adelaide Forensic Science Centre for an autopsy. It was done by Dr Manock without any other doctor present. He concluded that the cause of death was bronchopneumonia. He said that there was also a heart defect, although he did not undertake any microscopical examination of the heart tissues. He noted that there was a circular mark on the buttock which was consistent with a burn. However, he said that it was probably a healing area of nappy rash. He also noted that there were bruises on the baby’s back, which were consistent with finger pads. In his view, the microscopical examination of the tissues confirmed the diagnosis of bronchopneumonia. 

Dr Manock reported that there were three bruises on Storm’s scalp behind the left ear and that the brain was somewhat oedematous (swollen with fluid). A specialist in neuropathology subsequently examined the brain and noted that there may have been some damage to the brain stem. Dr Manock stated that he found no fracture of the skull. He saw X-rays of multiple rib fractures and said that the history of the child’s birth might help to explain some of them. He took the view that a hairline fracture of the eleventh rib may have been explained by the fall on the way to the ambulance. He said that some of the rib fractures might have been caused by ‘rough play’, such as throwing the baby in the air and catching him again.

A detective of the Criminal Investigation Branch (CIB) who attended the autopsy told the inquest that when he suggested that the fractures could not have come about in that way, Dr Manock appeared irritated by him. He said that Dr Manock's explanation for the injuries meant that there was no evidence to suggest that the death was caused by anything other than natural causes. [4]

The detective had earlier carried out other investigations, interviewing a neighbour and Craig. Craig had suggested that he might have murdered his son at the hospital by strangling him. When the detective heard this he arrested him. However, Craig was later released when the doctor said that his actions at the hospital would not have contributed to the death. The detective said that he felt frustrated that the investigation couldn’t go any further as a result of Dr Manock’s autopsy report.

The Coroner said that the parents’ evidence of a normal family life appeared at odds with what he described as Craig’s ‘rather menacing appearance’ – he was dressed in black clothes, leathers and studs. Craig was said by one witness to have a ‘short fuse’. [5]

Dr Terry Donald, the director of Child Protection Services at the Children’s 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 two occasions before death.

In the 4 Corners program, he said:

“I'm used to working with people who have a high standard of professional practise, and I was finding it difficult to believe. These injuries were actually dismissed as being caused by somebody else. It was as though, I think, one of the children was meant to have been harmed through rough play. I mean, for heaven's sake, you know, these were babies. They're not children that would be harmed by rough play at all. “

Dr Byard, a leading paediatric pathologist in Adelaide, said at the inquest that tissues from a number of areas of Storm’s body should have been examined microscopically. These included: the buttock lesion, which Dr Manock said he did examine, and concluded from this that it was not a burn; the rib and skull fractures, which were not done; the brain, which was not done by Dr Manock before he expressed his opinion, but was later done by the neuropathologist; and the eyes, which were not done.

Dr Byard also said that there should have been a detailed examination of the waterbed because of the possibility of accidental suffocation. This had not been done either. The Coroner took the view that it was not possible to resolve the conflicting evidence with regard to the skull fracture.

One of the doctors said that Craig appeared ‘enthusiastic’ when the other doctor discussed the withdrawal of life support. He described Craig as a ‘violent’ and ‘muddle-headed’ person and completely rejected the cause of death as being bronchopneumonia.

The Coroner commissioned Dr Thomas as an independent expert. He was an associate professor in anatomical pathology at the Flinders Medical Centre in Adelaide who had had forensic pathology experience in the United Kingdom and New Zealand as well as Australia. The Coroner said that ‘Dr Thomas was at that stage the Senior Specialist in tissue pathology at the Institute of Medical and Veterinary Science in Adelaide. He has wide experience both in histopathology and forensic pathology and, more recently, in cardiac pathology’.

Dr Thomas prepared a report on all the matters related to Storm’s death. In his report and evidence during the inquest, he stated that there were many areas where microscopical examination and weighing of organs were not done. He said even the body itself had not been weighed or measured. Some of these practices were described by Dr Thomas as ‘time honoured’. He said that in his view it was clear that bronchopneumonia was not the cause of death and that the injuries were not related to birth trauma. In his view they were not accidental.

The Coroner took the view that as Dr Manock had been the head of forensic pathology in South Australia since 1968, his understanding of the criminal process, and his obligation to provide lines of inquiry to investigators, would have been second-nature to him. Yet he had fundamentally failed to do that in Storm's case. The Coroner said that ‘it is extraordinary’ that Dr Manock did not conduct further enquiries to exclude the possibility of non-accidental injuries. [6]

Dr Manock's explanation to the Coroner was that ‘It was important that the pathologist should be careful not to influence the investigation and suggest suspicion which is unwarranted’. [7]

However, the Coroner said:

“People involved in child protection agencies, police and prosecuting authorities are placed in an invidious position when they are presented with evidence which is less than completely thorough and illuminating in such cases. The courts (whether it is a coronial or a criminal court) rely upon the validity and credibility of such evidence.

…If guilt can be established, it should be established to the extent to which the system is capable. If innocent people are to be exculpated, then no questions should remain about the thoroughness of the investigation which might throw a doubt upon their innocence.”[8]

At the conclusion of his examination of Storm’s case, the Coroner said, ‘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’. [9]

He said that the cause of death would have to be recorded as ‘undetermined’. It was his view that while a proper examination of the issues had not occurred, it was then too late to go back and put things right. 

Billy Barnard

Billy was born on 29 October 1992 to Cherry and David. He lived with his parents and an older sister aged three years. Another sister had died when she had been only three weeks old. On the evening of Thursday 30 July 1993, Cherry was in a sleeping-bag with Billy. The following morning, she said, she found him not breathing. She called for an ambulance and the baby was taken to the Adelaide Children’s Hospital. Billy was pronounced dead shortly after arrival. One ambulance officer said he had remembered attending at that address before when the other child had died. The ambulance officers noted that Cherry seemed ‘detached’, ‘nonchalant’, ‘unconcerned’ – much the same as on the first occasion. The ambulance officer conveyed his misgivings to the medical authorities on arrival at the hospital.

The physical examination of Billy by Dr Donald (the director of Child Protection Services) revealed injuries such as bruises and fractures, that were possibly non-accidental, as well as scars which were unusual in a child that young. The body was sent to the Forensic Science Centre for an autopsy.

Dr Manock conducted the autopsy and again, no other doctor was present. His diagnosis was that Billy, too, had died of bronchopneumonia. He also had arm fractures . A detective from the CIB said that he couldn’t undertake further inquiries because he was told that the cause of death was bronchopneumonia.

Cherry, when talking about Billy, admitted to having ‘cracked and snapped his arm’. Billy's sister had also died while sleeping with her mother in a sleeping-bag. The Coroner said that David was more articulate and careful in his answers to questions than Cherry was. The Department of Family and Community Services had had extensive involvement with the family, and there was evidence of neglect and poor parenting skills. Cherry had had a disturbed childhood, as had David, who had served a sentence for assaulting a child in an earlier relationship. The Coroner said that the Family and Community Services plan was clearly insufficient.

During the inquest, Dr Manock said he could not recall why he did not weigh the lungs. He agreed that bronchopneumonia was unlikely to have been the cause of death. He was unable to recall what he had seen in the slides that had led him to this conclusion. Dr Manock said he did not send the brain 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 that he was perplexed at this statement as Dr Blumbergs (the specialist) was 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.”[10]

The fact that the Coroner was unable to accept Dr Manock’s explanation, and that he regarded Dr Manock’s explanation as ‘spurious’, is a serious thing to say about someone in Dr Manock’s position, giving evidence under oath.

Dr Tony Thomas also evaluated the pathology evidence in this case for the Coroner. 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 again he described as a time-honoured practice. He said that there was no list to identify the origin of tissues that had been taken for examination. The absence of this made interpretation of those tissue samples difficult.

The Coroner took the view that the ‘bronchopneumonia’ explanation had caused the death to be ‘written off’ as a ‘natural’ death. He said that the investigation was basically cut off before it began.

As in the previous case, the Coroner concluded that the autopsy in Billy’s case achieved the opposite of its proper purpose, Dr Manock’s report having ‘closed off’ lines of investigation rather than opening them up. He said that the lack of a thorough investigation was disturbing, particularly as this was the second such death in this family, and in strikingly similar circumstances.

Joshua Nottle

Joshua was born on 27 November 1992 to Julieanne and Sean. He had a brother who was about two years old. On Tuesday morning, 17 August 1993, Joshua was found dead in his cot. He was taken to Modbury Hospital where he was declared dead. Bruising and rib fractures were noted. Two detectives from the CIB attended. After an interview, Sean was arrested and charged with Joshua's murder. When the results of the autopsy were known, this was then reduced to intentionally causing grievous bodily harm.

Joshua's body was transferred to the Forensic Science Centre where Dr Manock conducted an autopsy the same day. Again, there was no other doctor present during the examination, however the CIB officers were present. Bruising was found in addition to a spine fracture and rib fractures. Yet again, the death was described as bronchopneumonia, this time associated with multiple rib fractures.

Knowing that there was evidence of spinal injury and multiple rib injuries, the detective investigating the case spoke to Dr Manock about his concerns. He said that Dr Manock explained to him that throwing the child into the air and catching him could have caused the rib injuries. Dr Manock also said that the spinal injury might have resulted from ‘vigorous attempts at resuscitation’ by the father. Dr Thomas took the view that this was not correct. As the Coroner said:

“Dr Manock’s evidence here reflects his apparent attitude that this is an issue of credibility, that it is his word against that of Dr Thomas rather than an issue of scientific and professional method. Had Dr Manock done as Dr Thomas suggested he should have, this would not, and should not, have been an issue at all.” 

During the inquest, Dr Manock said that the baby was weighed but that the weight had been misplaced. Dr Manock said that he had 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. [11]

Unhappy with Dr Manock's explanations, the detective saw the director of Child Protection Services at the hospital (Dr Donald) who disagreed with Dr Manock’s explanations. Dr Donald said that the degree of force required to cause the type of injuries sustained by Joshua would be much greater than that proposed by Dr Manock. Dr Donald said that the spinal injury in Joshua's case was typical of those seen in young children who had been involved in high-speed car accidents, particularly when a child had been thrown from the vehicle. In the 4 Corners program, he dismissed the suggestion that it could have been caused by ‘vigorous attempts at resuscitation’. He also dismissed the idea that the rib injuries in this and the other cases could have been caused by ‘rough play’.

Dr Byard, the specialist in child pathology, advised the police that the rib fractures were most likely 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 thought that the lung weights did not support the view of bronchopneumonia. He was ‘mystified’ by Dr Manock’s suggestion of ‘bronchospasm’. This is a twitching of the muscles – a physical process and that could not have been seen at autopsy. [12]

Shaking babies can often cause brain damage. One of the classic signs of this is ruptured blood vessels in the eyes, which can be detected if the eyes are dissected at autopsy. The Coroner said it was ‘as a result of Dr Donald’s suggestion (not, as Dr Manock’s report implies, on his own initiative), Dr Manock agreed to dissect the eyes for signs of severe shaking’. [13] No ruptured vessels were found.

As with the previous two cases, the independent report by Dr Thomas was critical of Dr Manock's autopsy. It showed that no body height or weights were given. There appeared to have been no microscopical examination of the bruises. Organs, other than the lungs, were not weighed. The rib fractures were noted, but not the fractures of the clavicles (collarbones), which were easily detected on the X-rays. Dr Thomas took the view that a full skeletal survey was essential and that further dissection and microscopical examination was also essential. He was quite clear in saying 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 and that microscopical examination of the eyes should have been done and that the brain should also have been examined in this way. He said that the ‘time- honoured practice of taking the temperature’ was not done. Again, there was no list in relation to the tissues that were taken, making microscopical interpretation of those sections extremely difficult.

Dr Thomas agreed with Dr Byard that a bronchospasm would have been undetectable after death.

The detective investigating Joshua's case said that had he had the information later available in Dr Tony Thomas's report, the subsequent investigation would have been a great deal different.

The Coroner noted that Joshua's mother, in giving evidence, said that Sean was abusive to the children and to her. She said that he was violent when she became involved with another man. She would then spend nights at this other man’s place, leaving the children with Sean. She then allowed Sean to move with her, the children and this other man to their new address. She said that Sean would slap or hit the baby, but that she did not report this to the authorities because she was too scared. Sean denied the abuse, however, he could not explain what the Coroner called the ‘horrific injuries’ to the baby, or the bite-mark on the baby’s face. [14]

The Coroner said that when Joshua had been previously admitted to hospital, one had to conclude either that the bruising was not noticed, or that the notes were not acted upon. He said that ‘the witnesses have been unsatisfactory, and know more than they are prepared to tell’. He agreed with Dr Thomas that the autopsy had been inadequate. [15]

Dr Manock’s effect on the investigations

The Coroner concluded that, of the three deaths, that of Joshua Nottle was the most serious as the non-accidental injuries were the 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:

“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.” [16]

The Coroner 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 serious physical injuries remained undetermined. The uncertainties that now surrounded his death were most disturbing, but although there were grounds for grave suspicion, nothing could be proved on the basis of the evidence as it then stood.

Of the fractures, Dr Terry Donald said in the 4 Corners program:

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

Given that the re-examination of the lungs didn’t show any evidence of bronchopneumonia, Sally Neighbour asked Dr Tony Thomas on the 4 Corners program how a pathologist could possible come to that as the cause of death.  He replied:

“I can’t answer that. Given that bronchopneumonia is a basic inflammatory disease, perhaps I could answer by saying that I would have expected a first or second year trainee in anatomical pathology to be able to diagnose that down a microscope. “

When asked several years later in a television interview whether he was concerned about the criticisms of Dr Manock raised in these ‘Baby Deaths’ cases, the Director of Public Prosecutions, Paul Rofe, QC, said:

“I mean everything concerns me. But my understanding was that those mistakes, as the Coroner subsequently found, were as the result of post-mortems on babies and young children requiring a special skill which Dr Manock didn't possess and indeed didn't profess to possess. [17]

However, the Coroner found that Dr Manock had seen things which could not have been seen (such as bronchopneumonia) and that some of his answers to the Coroner’s questions had been ‘spurious’. It is not correct to suggest that these are the sorts of mistakes which arose because the cases involved babies and young children.

Heart attack, not heat stroke

An 18-year-old schoolboy died suddenly playing football on a rugby tour from England. The team had played in Sydney, Brisbane and Cairns before arriving in Darwin on 4 August 1999. The next day they played a game early in the evening. Towards the end of the game, the young man fell backwards and began to twitch. He was unconscious and his breathing was laboured. Resuscitation attempts failed. Dr Manock performed the autopsy and determined that the schoolboy had died as a result of heat stroke.

Once again Dr Thomas was asked to provide a second opinion on one of Dr Manock’s autopsies, but this time the request was from the Coroner of the Northern Territory.

Dr Thomas determined that the diagnosis of heat stroke was wrong, and that the boy had in fact died as the result of a heart defect. [18] ‘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.’

Dr Thomas made the following points in his report. The symptoms of sudden cardiac death and heat stroke are different, and the boy had not been playing long enough to develop heat stroke. In interpreting the heart weight, Dr Manock had failed to take into account the body weight. Also, the lungs were slightly heavy (a normal finding at autopsy), but not twice as heavy as Dr Manock stated, and Dr Manock’s interpretation of ‘interstitial haemorrhage’ within the heart was not correct.

Dr Thomas said that the information provided in the autopsy report was grossly inadequate and that a more comprehensive examination of the heart should have been performed. He said that Dr Manock’s statement that the lungs showed signs of a muscle spasm was wrong. Such a spasm cannot be detected after death; it cannot be seen either macroscopically or microscopically.

In this chapter we have seen that these cases have been based upon inadequate autopsy examinations, inadequate documentation and inappropriate interpretations of the evidence. All these issues were to be raised again in the Keogh case, as we will see in the next two chapters. The South Australian Coroners Findings criticising Dr Manock in the Baby Deaths cases were completed by August 1995 and, as we will see, this was the time when Henry Keogh’s second trial was being conducted.

Endnotes

1. Mr Wayne Chivell, Coroner for South Australia, Finding of Inquest into the Deaths of Storm Don Ernie Deane, William Anthony Barnard, Joshua Clive Nottle, , 25 August 1995.

Report of Dr AC Thomas on the Deaths of Storm Don Ernie Deane, William Anthony Barnard, Joshua Clive Nottle, 11 February 1994.

Dr CH Manock, Autopsy Report on Storm Don Ernie Deane, 27 October 1992.

Dr CH Manock, Autopsy Report on Joshua Clive Nottle, 24 August 1993.

Dr CH Manock, Autopsy Report on William Anthony Barnard, 15 September 1993.

‘Expert Witness’, 4 Corners, television program, ABC TV, 22 October 2001.

2. See, Chivell, Finding, ref. 1, pp. 3, 9.

3. Address by Mr Moss (Counsel Assisting the Coroner), transcript, p. 979.

4. See, Chivell, Finding, ref. 1, pp. 8, 27.

5. Ibid., p. 10.

6. Ibid., p. 25.

7. Ibid., p. 26.

8. Ibid., p. 88.

9. Ibid., p. 27. (Emphasis added)

10. Ibid., p.52.

11. Ibid., p. 77.

12. Ibid., p. 72.

13. Ibid., p. 59.

14. Ibid., pp. 60–5.

15. Ibid., p. 82.

16. Ibid, p. 82.

17. Interview by Rohan Wenn, Today Tonight, television program, Channel 7, (Adelaide), recorded 27 June 2002.

18. The information in this section is taken from Dr Thomas’s ‘Anatomical Pathology Report’.

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