Coronial Inquiries Research Articles

OBITUARY: Shirley Shackleton: A Timor-Leste hero's quest for truth

Shirley Shackleton said that after her husband Greg was killed in Timor-Leste in October 1975, for seven weeks she became a campaigner for justice for the journalists murdered in Balibo, then after Indonesia invaded in December 1975 she became a campaigner for justice for all the East Timorese too. Shackleton saw the Australian government treatment of the killings as a litmus test of Australian East Timor policy. She continued to pressure the government for a Federal Police investigation of those responsible for the deaths, culminating with Australian politicians and diplomats being put in the dock and scrutinised under oath in a Coronial Inquiry in 2007.

A return to Hayman Island: revisiting Australia’s only recorded cone snail fatality after 85 years

The death of Charles Hugh Garbutt from a cone snail ‘sting’ inflicted at Hayman Island on the Great Barrier Reef marked both a family tragedy and an important moment in Australian medical and malacological history. However, aside from newspaper reports and the few witness statements given at the coronial inquiry, the events of that day in June 1935 and its immediate aftermath have never been critically evaluated. As memories of what happened have either faded or been partly distorted with the passage of time, the fatality today remains only a footnote in the history of studies on the Conidae and their complex, pharmaceutically-valuable venoms. The species involved, Conus geographus Linnaeus, 1758, is now recognised as the most dangerous to humans of the Conidae and responsible for most and possibly all recorded fatalities. After 85 years, the case is revisited using available evidence including newspaper reports, relevant scientific and popular literature, witness statements, archival documents and the actual specimen responsible for the fatality. While tragic and probably avoidable, the death, via its extensive coverage by the press, undoubtedly has helped to save lives by educating a public largely unaware of the dangers from something as seemingly harmless as a sea snail. It is also concluded that Charles Garbutt, when all factors are considered, was most unfortunate to have lost his life in the way that he did. For future cone envenomations it is recommended that photography (if possible) of the specimen involved would assist both in patient reassurance and medical treatment.

A death sentence for swearing: the fatal consequences of the failure to decriminalise offensive language

ABSTRACT Several commissions of inquiry have recommended the reform or abolition of laws that criminalise the use of offensive language in Australia. These criminal offences have been linked to the over-policing and deaths in custody of Indigenous Australians. Australian state and territory governments have not only ignored these recommendations; they have also added new weapons to the police officer’s arsenal to control and punish swearing in public. Through an analysis of several case studies sourced from coronial inquiries and the Royal Commission into Aboriginal Deaths in Custody, this article argues that there is a need for urgent reform of laws that criminalise offensive language.

Pharmacists' perceived responsibility for patient care when there is a risk of misadventure: a qualitative study.

To investigate how community pharmacists view their responsibility for patient care in a scenario involving opioid use with significant risk of toxicity or misadventure. A case scenario was developed based on an Australian coronial inquiry involving a patient suffering fatal toxicity following misuse of opioids. Community pharmacists working in Brisbane, Queensland, were invited to take part in face-to-face semi-structured interviews at their place of work. Participants were asked how they would respond to the scenario in practice and their perceived responsibilities. Twenty-one pharmacists were interviewed. Participants identified similar actions in response to the case, and potential barriers and enablers. Participants differed with regard to how they described their perceived scope of practice and degree of responsibility in response to the case. Most participants described their scope of practice in terms of medication management with a focus on patient outcomes. Some participants described a narrower scope of practice that focused on either medicine supply or legal aspects. Participants who described a medication management focus differed in their views regarding their responsibility for patient outcomes in the case. Pharmacists in this study varied in terms of their perceived scope of practice and responsibility to patient outcomes in response to a case involving a patient at risk of opioid-related harm. Further work on pharmacist responsibility may reduce this variability.

Medicalizing the Detention of Aboriginal People in the Northern Territory: A New/Old Regime of Control?

The forcible removal and detention on reserves of many of Australia’s Indigenous people during much of the 20th century was pervasive and, according to Penny Pether, influenced her understandings of indefinite detention in other areas. She was interested in proliferating regimes of indefinite detention used as a technique to govern ‘dangerous’ populations. In this article, we examine how alcohol management schemes introduced in the 21st century in the Northern Territory, under the guise of welfare, continue the systemic confinement and control of Indigenous lives. The feared population has been reconstituted from one requiring protection as the remnants of a dying race, to one comprising vulnerable and criminogenic alcoholics who need to be detained for their own and others’ safety, and so they can be treated. We trace the genealogy of laws enabling the civil commitment of inebriates and addicts to show that in the form taken in the Northern Territory, the law has been aimed at the control and containment of a perceived antisocial population, rather than their treatment. Rather than protecting vulnerable people, the regime relied on techniques of detention and coercive treatment that continued the colonial state’s production of their Indigenous ‘vulnerability’. We examine this through the lens of the findings of a coronial inquiry into the death of an Indigenous woman in 2014, while detained for treatment and the subsequent evaluation of the Northern Territory’s Alcohol Mandatory Treatment Program.

The Cost of Youth Suicide in Australia.

Suicide is the leading cause of death among Australians between 15 and 24 years of age. This study seeks to estimate the economic cost of youth suicide (15–24 years old) for Australia using 2014 as a reference year. The main outcome measure is monetized burden of youth suicide. Costs, in 2014 AU$, are measured and valued as direct costs, such as coronial inquiry, police, ambulance, and funeral expenses; indirect costs, such as lost economic productivity; and intangible costs, such as bereavement. In 2014, 307 young Australians lost their lives to suicide (82 females and 225 males). The average age at time of death was 20.4 years, representing an average loss of 62 years of life and close to 46 years of productive capacity. The average cost per youth suicide is valued at $2,884,426, including $9721 in direct costs, $2,788,245 as the value of lost productivity, and $86,460 as the cost of bereavement. The total economic loss of youth suicide in Australia is estimated at $22 billion a year (equivalent to US$ 17 billion), ranging from $20 to $25 billion. These findings can assist decision-makers understand the magnitude of adverse outcomes associated with youth suicide and the potential benefits to be achieved by investing in effective suicide prevention strategies.

How do weather and terrain contribute to firefighter entrapments in Australia?

Adverse weather conditions and topographic influences are suspected to be responsible for most entrapments of firefighters in Australia. A lack of temporally and spatially coherent set of data however, hinders a clear understanding of the contribution of each weather type or terrain driver on these events. We investigate coronial inquiries and internal fire agencies reports across several Australian states from 1980 to 2017 and retrieve 45 entrapments. A first analysis reveals that most entrapments happen during large fires and that the number of deaths has decreased over the last few decades. Comparing the meteorological and topographical conditions of the entrapments with the conditions of a reference set of fires without entrapment, we build a linear regression model that identifies the main contributors to firefighter entrapment. A change in wind direction, which was associated with 42% of the incidents examined, is the main factor contributing to entrapments. Interaction between strong winds and steep slopes also influences the likelihood of entrapment and suggests that dynamic fire behaviours may also play important roles. As further details of this relationship between dynamic fire propagation and firefighter entrapment is now required, the understanding of weather and terrain contribution is a first step to produce comprehensive safety guidance.

Justice for Ms Dhu

Ms Dhu, an Aboriginal woman belonging to the Yamatji nation, died in police custody in South Hedland, Western Australia, in 2014 within 48 hours of being incarcerated for failing to pay fines. The coroner’s report found that both the police force and medical institution failed to discharge the duty of care owed to Ms Dhu, as their behaviour fell below what was expected of someone in their position. However, the coronial inquiry was unable to account for the ways in which state power and possessive sovereignty is invested in the deaths of Indigenous peoples. This article connects Ms Dhu’s life and death to forms of gendered, institutional and structural racism endemic to the Australian settler state. We then turn to examine the possibilities of justice for Ms Dhu through aesthetic attempts to memorialize her in public spaces of the city of Perth, which carry a promise of justice through their ability to challenge the settler-colonial logic that made possible Ms Dhu’s invisible suffering and the lack of accountability for her death.

Legal Narratives, Human Trafficking and Slavery in Australia

AbstractIn this paper, I will explore the Australian context of human trafficking and slavery by reviewing narratives drawn from two separate coronial inquiries into the deaths of two people who were never legally recognised as being trafficked into Australia. Puongtong Simaplee died in Villawood Detention Centre in Sydney on 26 September 2001, and Manjit Singh died on 26 August 2011 in the intensive care unit of a Sydney hospital from complications of surgery.

Farm suicides in New Zealand, 2007-2015: A review of coroners' records.

Economic recessions and severe weather events are often associated with increased suicide rates. The Global Dairy Crisis 2015/2016 led to an economic downturn in the New Zealand dairy farming industry and, coupled with droughts in some regions and floods in others, raised fears about increased suicide rates among farmers. However, little was known about suicides in the farming sector. This study reviews characteristics of recent farm-related suicides in New Zealand and assesses the extent to which financial stresses contributed to the deaths. Data were abstracted from coroners' records for a consecutive series of 185 people in farm- and agriculture-related occupations who died by suicide between 2007 and 2015 and for whom coronial inquiries had been completed. Farm suicides were heterogeneous: six distinct risk profiles were identified. Financial stresses made negligible contributions to farm suicides. Overall, risk factors for farm suicides differed little from risk factors for suicide in the general population. However, suicide risk in farmers was exacerbated by ready access to firearms: almost 40% of farm suicides involved firearms, compared to 8% in the general population over the same time. Among farm suicides, young male farm labourers predominated, rather than farm owners or managers. For many young men, relationship losses, acute alcohol intoxication and ready access to a firearm formed a common constellation of risk factors. While coroners' records are variable and do not record specific information about financial stresses and weather events, it was clear that these issues made a negligible contribution to farm suicides. A range of rural suicide prevention initiatives are needed to address various farm suicide risk profiles. In particular, young male labourers often had no contact with health services prior to death, suggesting that rural suicide prevention efforts need to be positioned within community, farming and sports organisations, as well as health and social service providers.

Not addressing the root cause: An analysis of submissions made to the South Australian Government on a Proposal to Protect Midwifery Practice.

Reports of unregulated birth workers attending birth at home, with no registered midwife in attendance (freebirth), have become more frequent in Australia in recent years. A Coronial Inquiry (2012) into the deaths of three babies born at home in South Australia resulted in a call for legislation to restrict the practice of midwifery to registered midwives. A Proposal to Protect Midwifery Practice in South Australia was issued as a consultation paper in January 2013. To report the views of those making a submission to the Proposal to Protect Midwifery Practice in South Australia. Thirty submissions to the South Australian Government were downloaded, read and thematically analysed. Twenty-five (81%) submissions supported the legislation, 5 (16%) opposed it and 2 (6%) were neither for nor against. Support for the proposed legislation was strong, however the underlying root causes that have led to the rise of UBWs attending homebirth in Australia were not addressed. Recommendations called for all stakeholders to work with women to develop a better framework of care that respected and met their needs and choices whilst safeguarding maternal and neonatal health. The Proposal to Protect Midwifery Practice may promote greater protection of midwifery practice however, Private Indemnity Insurance (PII), collaborative agreements and power struggles associated with the medical domination of childbirth continue to marginalise homebirth and prevent women from accessing the care they want and need. These unresolved issues represent the root causes for UBWs attending homebirth; hence the proposal is only a partial solution.

Australian wildfire litigation

Legal liability is an issue that concerns volunteer firefighters and may affect the ability of fire managers to perform their tasks. There are calls to guarantee firefighters will not be personally liable for actions undertaken in good faith. This paper reviews post-wildfire litigation in Australia and claims for compensation made against the New South Wales Rural Fire Service. Although the data are incomplete and likely to underestimate the actual claims history, analysis of the available data does show that the number of claims for compensation is small given the very large number of fires and hazard reduction burns across Australia. There is no evidence of extensive post-fire litigation or of fire agencies or firefighters being held liable for actions taken in the course of firefighting The evidence does not support assertions that there is an ‘increasing flood’ of legal claims arising from firefighting. Post-fire litigation is compared with other proceeding such as Royal Commissions and coronial inquiries. It is argued that it is not liability, but the lengthy post-event inquiry process and the risk of personal criticism that should be the concern of fire managers and firefighters.

‘Turning a blind eye’: denying people their right to treatment for acute alcohol, drug and mental health conditions – an act of discrimination

Background: Australians seeking health care from any public hospital have the right to non-discriminatory safe medical assessment, treatment and nursing care. The literature clearly indicates that people presenting to public hospitals with acute alcohol- or drug-related conditions are at risk of dying by being denied medical and nursing treatment. This denial of treatment is on the basis that their presumed condition is solely drug- and alcohol-related. There is often even a greater risk for Aboriginal people who present for treatment. This literature comprises reports from coronial inquiries, police incidents, safety audits, and critical incidents in health services, and anecdotal information from specialist drug and alcohol nurses. Such violation of this vulnerable population's right to safe health care has often resulted in suicide and other preventable deaths, disability and exacerbation of physical and mental illness. Method: A critique was conducted of recent available Australian ‘grey’ literature c...

M. C. Dillon and N. D. Westbury: Beyond Humbug: Transforming Government Engagement with Indigenous Australia

According to anthropologist W.E.H. Stanner, an elderly Aboriginal person once summed up nonIndigenous (European) Australians for him, in eight words: ‘‘Very clever people, very hard people, plenty humbug’’ (Stanner 1969, in Dillon and Westbury 2007, p. 207). This anecdote fronts the concluding chapter of Dillon and Westbury’s: ‘Beyond Humbug: Transforming Government Engagement with Indigenous Australians’, self-published through Seaview Press in 2007. It captures the book’s core intention of shifting the focus in Indigenous affairs, away from a politicised ‘blame the victim’ pre-occupation which asks: ‘what’s wrong with Indigenous cultures and communities?’, and onto the public policy context: ‘what constitutes appropriate and effective public policy engagement?’ Between them, Dillon and Westbury have decades of senior public service experience in Indigenous affairs, policy and administration. They suggest from the outset that the root cause of the continuing entrenched disadvantage of Australia’s Indigenous populations is a longstanding absence of ‘‘coherent policy engagement by governments at all levels underpinned by the absence of determination and political will’’ (2007, p. 4). While acknowledging the heterogeneity of Australia’s .5 million Indigenous peoples, their languages, cultural and locational diversity, the authors’ focus specifically on government dis/engagement with the (approx) 25% of the Indigenous population who remain living, or have returned to live, on their traditional lands in ‘remote’ and ‘very remote’ settlements. Across the 86% of the Australian continent classified as ‘remote’ or ‘very remote’ there are some 1200 Indigenous communities organised in small dispersed settlements. Australia’s Indigenous population is growing at a rate exceeding that of the non-Indigenous population and over the next decade, in remote areas, is predicated to increase by between 20–24% in the arid zones and 38–42% in the wet tropics (Dillon and Westbury 2007, p. 24). At the same time, Indigenous communities suffer entrenched, inter-generationally embedded and disproportionate rates of socio-economic disadvantage on every criterion of health, employment, income, housing and mortality. Indicators of Australian Indigenous disadvantage have stagnated at shocking levels of disparity with nonIndigenous counterparts and lag well behind the comparative improvements in Indigenous well-being evident in western democracies such as New Zealand, Canada and the US. As a Coronial Inquiry into deaths by petrol sniffing in remote areas commented: ‘‘that such conditions should exist among a group of people D. Tedmanson (&) School of Social Work & Social Policy, University of South Australia, Adelaide, Australia e-mail: deirdre.tedmanson@unisa.edu.au

Deaths in Private and Public Prisons in Australia: A Comparative Analysis

Public opinion in Australia has been divided on the question of whether private prisons are welcome and one of the issues in dispute has been the question of whether or not private prisons are associated with proportionately more or fewer deaths of prisoners, particularly suicides, than public prisons. The available evidence is examined, and when the number of deaths, or suicides, per 1000 prisoner years served for all private and public prisons are calculated it is found that the rate for all deaths is significantly lower in private prisons at the 0.05 level of confidence. However, the difference in the suicide rates is not statistically significant.The lower overall death rate is particularly surprising as private prisons in Australia hold proportionately more unconvicted remandees,who are at higher risk, than public prisons. A close examination of the data for three relatively new remand and reception prisons, two private and one public, shows that all have much higher rates for both all deaths and for suicides than the national averages. This is an updated and expanded version of a paper by the same authors published by the Australian Institute of Criminology in June 1999. That paper was admitted into evidence at a coronial inquiry that was held into five deaths that occurred in the Port Phillip Prison in Victoria. Address for correspondence: D. Biles, 25 Kidston Cres, Curtin ACT 2605, Australia.

A South Australian Coronial Inquiry Into Suicide and Homicide

Objective: To review the findings of an Australian Coronial inquiry into suicide and homicide associated with mental illness and to compare those findings with a large UK report. Conclusions: Similar findings emerged from both inquiries. These included recommendations in regard to the adequate documentation of illness; the recognition of the role of relatives and carers; the optimum use of health care legislation to ensure compliance with treatment; and an awareness of the availability of the newer “atypical” anti-psychotic drugs. Such recommendations serve as a useful reminder of what good psychiatric practise should provide in contributing to a reduction in suicide and homicide by those with mental illness.

Carers at risk — some forensic implications of the devolution of mental health services

For several decades there has been a gradual reduction in the number of patients hospitalised in traditional psychiatric institutions. The pace of change has varied from one country and jurisdiction to another but in most western countries the era of the psychiatric asylum has passed and services, for the most part, are now located in the community or in short stay units attached to general hospitals. Psychiatrists (and other professionals) together with general practioners carry the responsibility of looking after a potentially difficult group of patients. Their care involves not only clinical considerations but also an awareness of, and sensitivity to, the requirements of society, in terms of public safety, and support and assistance to carers, both professional and family. Adequate funding and resources, ease of access to emergency services and quality communication between all components of the system are essential. A breakdown of any of these components can have serious and at times lethal consequences, particularly for carers. This article examines some of the forensic implications with respect to carers and their families in the context of the devolution of mental health services in South Australia. Three case histories, 2 matricides and the homicide of a doctor will be. discussed in detail. These were addressed in a South Australian coronial inquiry to which reference will be made. It will be postulated that such tragic events, wholly or in part, are attributable to the recent changes in the system. Finally, comment will be made on the difficulty providing centralised and statewide services in a specialised area such as forensic psychiatry, and the monitoring of the quality of such services, in an era of regionalisation and privatisation.

Liability for the unauthorized removal of cadaveric transplant material.

It has been assumed that the removal of cadaveric transplant material would result in liability being incurred, if not done in accordance with the Human Tissue Act 1961. This might not always be so. There are no established torts which would normally be applicable—although on general principles the unauthorized removal might well be actionable, on the ground that it constituted an interference with the right to possession of the person under a duty to dispose of the body. If this person had given his consent, he could not subsequently recover damages. Where the unauthorized removal obstructed coronial or police inquiries, or the course of public justice, a doctor would sometimes be criminally liable. However, in the usual case, it is not certain that the unauthorized removal would itself amount to any crime. In those cases where the unauthorized removal did bring the doctor within the range of some tort or crime, there is the possibility that he might be able to escape liability if his action was necessary to save the potential recipient's life.