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Springvale Monash Legal Service Inc The Coronial Process: Delays From Death To Inquest

Springvale Monash Legal Service Inc

The Coronial Process: Delays From Death To Inquest

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Contents

1. INTRODUCTION 4

2. CORONER’S COURT PROCESS 6

A. ROLE OF THE CORONER 6

B. REPORTING A DEATH AND INITIAL PROCEDURES 7

C. THE INVESTIGATION 7

(i) The Major Collision Investigation Unit 8

(ii) Homicide Squad Investigation 9

D. NOTIFICATION – WHEN AN INQUEST WILL NOT BE HELD 12

E. WHEN AN INQUEST WILL BE HELD 12

(i) When an Inquest must be held 12

(ii) Other Circumstances 12

(iii) Requesting an Inquest 13

F. NOTIFICATION OF INQUEST 13

G. THE INQUEST 14

(i) The Hearing 14

(ii) The Finding 14

3. DELAYS IN THE CORONER’S COURT PROCESS 15

A. REPORTING A DEATH AND INITIAL PROCEDURES 15

B. THE INVESTIGATION 15

(i) Time Constraints and Lack of Resources within Victoria Police

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(ii) Obtaining witness statements 16

(iii) Technical and Expert Reports 16

C. REQUESTING AN INQUEST 17

D. THE INQUEST 17

(i) Initial Listing and Case Management 17

(ii) Interested Parties 18

(iii) Adjournments to Clarify Issues or Obtain Additional Evidence

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4. CONCLUSION 19

(i) The Investigation 19

(ii) The Inquest 19

5. APPENDIX A 21

6. REFERENCES 25

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1. INTRODUCTION

The Office of the Coroner is charged with the role of investigating circumstances of

death. This is with a view to averting preventable deaths.1 In addition to this, the

Coroner’s finding is important to family members who may be relying on the finding in

litigation related to the death or to gain closure from knowledge of the circumstances of

the death. For these reasons it is in the public interest that the Coroner balance the need to

seek the full truth against the time taken to deliver the finding.

The length of time between death and inquest varies significantly from case to case. On

average it is approximately 2 years from death to inquest. The averages below have been

calculated from the information provided in Appendix A.

Circumstances of Death Number of Deaths Average time taken from

Death to Inquest

Police Shootings 16 2 years 2 months

Police Pursuits 6 1 year 9 months

Baby Death 7 2 years 1 month

Workplace Death 4 3 years 1 month

Medical/Hospital Death 6 2 years 4 months

Aviation Death 2 2 years 1 month

Fire 2 1 year

Drowning 2 2 years 4 months

Death involving Motor

Vehicle

4 11 months

A solicitor experienced in dealing with the coronial system indicated that there has been a

move towards a case management approach, where the Coroner assumes a greater role in

setting a timeline for the proceedings, however this approach has not been adopted

1 Interview with Coroner’s Assistant, Coroners Court 28 August 2004.

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throughout the coronial system2. It is hoped that the proposed system to deal exclusively

with work related deaths will result in speedier findings which in turn will serve the

public better by making work places safer, sooner.3

We have identified three specific consequences of delays in the coronial process:

i. The adverse effects on family members of the deceased can be

characterised as:

a. Need for family to find closure.

b. Difficulty in pursuing legal rights stemming from death.

ii. The adverse effects on the accuracy of the finding can be classified as:

a. Accuracy of witness statements

b. Difficulty in locating witnesses

iii. The public interest in speedier findings is in the prevention of preventable

deaths.

These adverse effects are best illustrated by way of a case study.

Case study: Mark Kauffman

Mark died on 19 January 2002 as a result of wounds sustained when shot by police. Mark

was suffering from a psychotic episode at the time. Due to these circumstances the death

was reportable and an inquest was to be held. The inquest was set down for 16 November

2004 and conducted in December 2004, concluding in March 2005. To date, the findings

have not been submitted by the Coroner and the family feels that the protracted coronial

process has extended their grieving period as they are unable to move past the death of

their son. They feel isolated from the coronial process as there has been minimal

communication between the Office of the Coroner and the family, apart from the

notification of inquest date. Throughout the investigation process they remained

uninformed of the progress or content.

2 Interview with solicitor 11 October 2004. Firm anonymous. 3 Coroner tackles fatal culture of repetition, The Age, 28 October 2004.

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http://newsstore.theage.com.au/apps/viewDocument.ac?page=1&sy=age&kw=Coroner&pb=age&dt=selectRange&dr=3months&so=relevance&sf=headline&sf=text&rc=10&rm=200&sp=nrm&clsPage=1&docID=AGE041028F27H24T5S8G


2. CORONER’S COURT PROCESS

A. ROLE OF THE CORONER

The primary role of the Coroner is to determine the identity of the deceased, the cause of

death and the particulars needed to register the death. In some cases the Coroner may also

comment and make recommendations about public health, safety or the administration of

justice.

Even where a death is not the result of a suspected homicide or other crime there are a

number of reasons why a cause of death should be adequately identified. Plueckhahn4

identifies the following reasons as important in determining a cause of death:

• Drawing attention to the existence of circumstances which if not remedied may

lead to further deaths

• To preserve the legal interests of the deceased person’s family, heirs and other

interested parties

• To assist in insurance claims or civil litigation

• To assist generally in medical care, medical education and medical research

• To provide an accurate statistical base of medical causes of death for medical and

educational purposes.

Plueckham believes that it is in the community’s interest to accurately identify the cause

of death because ‘these have a bearing on public health, the discovery of unidentified

diseases, safety in industry and on the roads, vehicle construction, health hazards and the

treatment and care of patients’5

It is not the Coroner’s role to establish whether a crime has been committed, to find a

person guilty of a crime or to establish the negligence of any party. The Coroner’s role is,

therefore, limited to fact finding and making recommendations.

4 V Pleuckhahn, Ethics Legal Medicine and Forensic Pathology (Melbourne University Press, 1983) p 9

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B. REPORTING A DEATH AND INITIAL PROCEDURES

The Coroner’s Act 1985 (“the Act”) requires certain deaths to be reported to the Coroner.

A ‘Reportable Death’ is a death that must be reported to the Coroner where:

• The person died unexpectedly

• The person died from accident or injury

• The person died in a violent or unnatural way

• The person died during or as a result of an anesthetic

• The person was ‘in care’ including

o deaths in police custody

o deaths in gaol

o death of an involuntary patient in a psychiatric institution

o death of a child in a juvenile justice centre

• A doctor has been unable to sign the death certificate giving the cause of death

• The identity of the person who died is not known

Immediately after ‘a reportable death’ the body is taken to the mortuary and a ‘Form 83’

is completed. Police provide a preliminary report to assist the pathologist performing the

autopsy.6

C. THE INVESTIGATION

The investigation into identity, cause of death and the circumstances surrounding the

death is undertaken by either Victoria Police or the State Coroner’s Assistants’ Unit .

Victoria Police generally investigate motor vehicle accidents, suicide, murder and

workplace deaths. The Coroner’s Assistants will investigate all medical or aviation

deaths. Within Victoria Police there are specialized investigation teams which will

investigate deaths according to the circumstances and type of death. Suspected murder

5 V Plueckhan, ‘Light at the end of the Forensic Tunnel’ (1986) 60 Law Institute Journal 60, p1059 6 Interview with Coroner’s Assistant, Coroners Court 28 August 2004.

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and manslaughter is investigated by the Homicide Squad and road deaths are investigated

by the Major Collision Investigation Unit.

In the case of workplace deaths the Victorian Workcover Authority provides a

comprehensive report to Victoria Police on any work related death.

All information gathered during an investigation is provided to the Coroner’s Office in

the Brief of Evidence. The Coroner’s Office is responsible for setting the deadline for the

submission of the Brief. This often depends on the complexity of the issues, the nature

and circumstances of the death and the number of witness statements that need to be

obtained. Often police officers will request, and are granted, an extension for submission

of the Brief.

Any Brief of Evidence received from Victoria Police is checked and any additional

investigation that is required is undertaken by the Coroner’s Assistant or the police

officer preparing the Brief.

The Coroner’s Assistant will then meet with the Coroner to discuss whether any

additional information is required.

(i) The Major Collision Investigation Unit

The Major Collision Investigation Unit (MCIU) is responsible for investigating all fatal

and life-threatening injury crashes. When MCIU initially attend the scene of an accident

they document all physical evidence at the scene and take photographs and measurements

which are used for any subsequent reconstruction of the collision.7

Formal statements are obtained from all parties involved and certain persons may be

formally interviewed. Autopsy reports on deceased persons are performed and blood

samples are analysed for alcohol and drugs.8

7 VACC interview with Sgt Peter Bellion, Victoria Police Major Collision Investigation Unit entitled ‘Crash Course’ [Internet – http://www.motor.net.au/VACC/Media/] 8 Id

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http://www/


Every vehicle that is involved in a fatality will have a mechanical inspection performed

by qualified mechanics attached to the Unit. There are currently three Senior Constables

and a Senior Sergeant that perform this role. The mechanical investigators receive a

‘jobcard’ from investigating police summarizing the circumstances found at the scene of

the accident. The mechanical investigators examine components of the vehicle involved

to determine whether there was any mechanical defect that caused or contributed to the

accident. Approximately 500 vehicles involved in fatal or life threatening accidents are

inspected by mechanical investigators each year.9

Other investigators apply physics and engineering skills to the physical evidence obtained

from the scene to assess how the accident occurred. Factors examined include speed,

perception-reaction responses, restraint systems, steering input, road conditions and force

of impact. Investigators also use computer simulation software to run simulations of the

crash. These look at braking inputs, speed changes during impact and the positions of

those injured or killed in the accident.10

Witness statements, mechanical investigations, physical evidence, simulations and

reconstructions form the basis of the export reports in the Brief of Evidence. Once the

Brief of Evidence is completed it is provided to the Coroner and/or the Prosecutor. The

complexity of the investigation depends on the nature of the collision, how many witness

statements are obtained and the nature and number of expert evidence reports required.11

(ii) Homicide Squad investigation

The Homicide Squad become involved in the coronial investigation upon referral of the

case from the Coroner. They are charged with compiling the Brief of evidence on which

the Coroner relies when delivering the finding. The Brief consists of:

• summary of death

• all details of death

9 Id 10 Id 11 Id

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• details of witnesses

• statement of witnesses

• Statements of experts consulted

• Possibly a police recommendation

The length of the Brief will depend on the complexity of the circumstances of death. For

example, a police shooting would require input from many expert witnesses such as

ballistic experts and treating psychiatrists. There could be up to 30 statements in any

Brief. The homicide squad generally work in a collegial manner in order prepare the

Brief, with a senior officer coordinating the efforts of the department.12

The length of time varies based on the extent of investigation required. A member of the

homicide squad indicated that on average the Brief would take two years to compile. The

police officers would work on the Brief more intensively if the matter necessitated urgent

response in the public interest. Multiple deaths arising out of a single incident would be

such a case.13

We note that Public Interest Law Clearing House (PILCH) regards eligible matters of

public interest as those that:

1. require a legal remedy or other legal assistance; and

2. affect a significant number of people; or

3. raise matters of broad public concern; or

4. impact on disadvantaged or marginalised groups.14

We believe that points 2, 3, and 4 relate the coronial process and stand to be prejudiced

by delays.

Upon completion the Brief is passed to the Coroner who may direct that further

investigation take place, or other avenues be pursued.

12 Interview with senior constable, Homicide Squad, 25 October 2004 13 Id 14 www.pilch.org.au

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http://www.pilch.org.au/


The police officer consulted in the Homicide Squad indicated that the time constraints did

not induce pressure in those involved, however it was acknowledged that it was preferred

to complete the investigation sooner than later. The officer did not believe that the

findings of the Coroner would be tainted by inaccurate witness recollection as statements

were taken soon after the event, and in most cases witnesses could be located.15

Once the matter proceeds to inquest the police remain involved by organizing the

proceedings in calling witnesses and tendering evidence. As inquests often deal with

systemic issues, and also do not actively involve criminal law, police interest and

enthusiasm in this part of the inquest (beyond the initial investigatory stage) may be less

intense.16 Essentially, the police are interested in how the individual died, as the Coroner

is interested in: “how… the deceased came about his death”.17

The above quote relates to circumstances leading to the fatality (which often are not

relevant to a criminal investigation), as opposed to the immediate act. For example, if an

individual suffering from mental illness was fatally wounded in a confrontation with the

police, police interest would essentially involve the criminal aspect of the case,

identifying the immediate circumstances leading to the death. They may interview

witnesses, conduct a series of technical tests and examinations of the scene, so as to

determine the level culpability of the shooter. On the other hand, the Coronial interest

would lie with long-term issues which led to the shooting. Were the police aware of the

severity of this individual’s illness? How much involvement have the various mental

health organizations had with this individual? Did various mental health workers attend

the scene? Was current police procedure appropriate given the circumstances? Was this

fatality avoidable?

15 Id 16 Interview with Coroner 28 June 2005 17 Criminal Law Investigation and Procedure, Vol 2, Freckleton 1, [2.23.330] Section 19 – Coronial findings and comments

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D. NOTIFICATION – WHEN AN INQUEST WILL NOT BE HELD

Family members and interested parties are formally notified 21 days prior to the Coroner

making a finding ‘in Chambers’. Parties then have an opportunity to submit any

particular questions, or to request that an inquest be held.

E. WHEN AN INQUEST WILL BE HELD

There are a number of circumstances in which an inquest will be held. The minimum

period between death an inquest is approximately 8 months. In more complex cases and

cases involving a large number of parties the period between death and inquest may be

considerably longer.18

(i) When an Inquest must be held

Under s17 of the Act the Coroner MUST hold an inquest where:

Homicide is suspected (however the Coroner usually awaits criminal proceedings

and can decide NOT to hold an inquest if someone has been charged and

convicted)

The person was ‘in care’

The person’s identity is not known

The Attorney General directs

(ii) Other Circumstances

The Coroner will also hold an inquest in other circumstances if the Coroner believes it is

desirable. An assessment is made by the Coroner before deciding whether an inquest will

18 Interview with Coroner’s Assistant, Coroners Court 28 August 2004.

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be held. This may occur where facts are unclear or there is an issue of public

importance.19

(iii) Requesting an Inquest

Interested parties can request the Coroner hold an inquest. This is done by writing to the

Coroner giving reasons why an inquest should be held20. Most inquests held in

circumstances outside of those which require an inquest under the Act are at the request

of families and interested parties. Under s17(2A) of the Act the Attorney General may

direct the Coroner to hold an inquest, however this is very rare21.

If the Coroner refuses or has not agreed to an inquest within three months of a party’s

request under s18 of the Act a person may apply to the Supreme Court for an order that

an inquest be held.

F. NOTIFICATION OF INQUEST

The Coroner’s Court ‘Listing Clerk’ is responsible for issuing summons and advice to

interested parties in relation to upcoming inquests. Family members are notified of an

inquest date by the Coroner. Under s42 of the Act the Coroner must publish the place,

date and time of the inquest at least 14 days before the hearing.

Interested parties must contact the registrar if they wish to formally participate in

proceedings. They are required to demonstrate their involvement in the death and the

reasons why they should formally participate in the hearing. 22

19 State Coroner’s Office Victoria website, The Coronial Process [Internet – http://www.Coronerscourt.vic.gov.au] 20 State Coroner’s Office Victoria website, The Coronial Process [Internet – http://www.Coronerscourt.vic.gov.au] 21 Interview with Coroner’s Assistant, Coroners Court 28 August 2004. 22 State Coroner’s Office Victoria website, The Coronial Process [Internet – http://www.Coronerscourt.vic.gov.au]

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G. THE INQUEST

(i) The Hearing

An inquest is a public hearing conducted by the Coroner. Hearings are held in the

Coroner’s Court at the Coronial Services Centre or, in the case of country hearings, at the

local Magistrates’ Court.

Although an inquest is similar in some ways to a civil or criminal court proceeding, most

rules of evidence and procedure do not apply and the inquest is conducted in an

inquisitorial rather than adversarial manner. The purpose of an inquest is to establish

certain facts and its purpose has been described as “seeking truth rather than justice”.23

During an inquest witnesses are sworn in, statements are read out and witnesses are

subjected to examination and cross-examination. A member of the State Coroner’s

Investigation Unit initially leads evidence from the witness. The legal representative of

interested parties also has the opportunity to question the witness. The Coroner may also

ask questions during the process. Where the victim’s family is unrepresented, a member

of the Coroner’s Investigation Unit will also ask the family if they would like any

questions answered.24

At any time the Coroner may request other witnesses or information if further evidence is

needed to clarify an issue or new issues arise. Hearings may be adjourned during this

process.

(ii) The Finding

Once all evidence is heard the Coroner will adjourn the case to complete their finding.

The finding may be given on the same day, but often is adjourned to a date in the future

23 Interview with Coroner’s Assistant, Coroners Court 28 August 2004. 24 State Coroner’s Office Victoria website, The Coronial Process [Internet – http://www.Coronerscourt.vic.gov.au]

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depending on the nature and complexity of the case25. The Coroner’s finding then

becomes public record.

3. DELAYS IN THE CORONER’S COURT PROCESS

A. REPORTING A DEATH AND INITIAL PROCEDURES

We did not identify any specific delays in this process as a ‘Reportable Death’ is reported

to the Coroner’s Office immediately and the body is transported to the mortuary at the

Coronial Services Centre. The Act clearly identifies those deaths which must be reported.

Autopsies and pathology reports must be performed as soon as possible after death. In

Melbourne, this process is assisted by the centralised nature of the Coronial Services

Centre. Autopsies are performed by a Forensic Pathologist at the Victorian Institute of

Forensic Medicine.

B. THE INVESTIGATION

The investigative process introduces delays into the Coronial process. As noted, the

minimum time noted from our research between death and inquest is eight months and

can be much longer depending on the case. The length of time required to investigate a

death depends largely on the nature and circumstances of the death and the complexity of

the issues that arise.

(i) Time Constraints and Lack of Resources within Victoria Police

We were advised that police officers responsible for the investigation of deaths often

request, and are granted, extensions for the submission of the Brief26. We have been

25 State Coroner’s Office Victoria website, The Coronial Process [Internet – http://www.Coronerscourt.vic.gov.au] 26 Interview with Coroner’s Assistant, Coroners Court 28 August 2004.

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unable to determine how, and to what extent, resource issues impact the investigative

process and the request and granting of these extensions.

There is no formal process for requesting or granting an extension and the decision to do

so is at the discretion of the Coroner’s Office27. It would appear however that it is

relatively easy to obtain an extension.

(ii) Obtaining witness statements

The number of witness statements that need to be obtained during an investigation and

any difficulties associated with this has a significant impact on the preparation and

submission of the Brief and the investigative process in general.

During our investigations we discovered that witnesses often refuse to provide the police

with a formal statement for legal reasons. In these cases the Coroner is forced to call

witnesses at the inquest28. We were advised by Margy Wilde-Brown, whose partner died

in psychiatric care in the ACT, that it was these difficulties that contributed to the

substantial delay between his death and the finding made by the Coroner (over 2½ years). 29

Although the Coroner has the power to call witnesses who refuse to give statements to

the inquest, the most efficient manner of investigating the death is to obtain these

statements prior to the inquest. As was the case with Margy Wilde-Brown, the calling and

questioning of witnesses who refused to provide police with statements often raised

additional facts and issues which required further investigation. In some cases this meant

that the inquest had to be adjourned for lengthy periods.

(iii) Technical and Expert Reports

Obtaining technical and expert reports clearly has some impact on the time taken to

complete the investigative process. Again, the length of time required clearly depends on

the nature and circumstances of the case and the complexity of the issues involved. This

27 Interview with Coroner’s Assistant, Coroners Court 28 August 2004. 28 Interview with Coroner’s Assistant, Coroners Court 28 August 2004.

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is illustrated in the discussion of the investigative role of the Major Collision and

Investigation Unit (MCIU). It would appear that mechanical inspections are undertaken

relatively quickly however the extent of any further investigation depends on the nature

of the collision, the number of cars involved, the number of witnesses and the

circumstances surrounding the incident. Information from other sources such as

manufacturers may also be required.30

Investigations carried out by the Homicide Squad are often subject to delays as the

investigating police officers await reports from other parties such as medical

practitioners.31

C. REQUESTING AN INQUEST

We did not identify any specific delays relating to the request of an inquest by interested

parties. It should be noted however that the Act provides that a person can apply to the

Supreme Court if they have not received a response from the Coroner’s Office within

three months of making the request. This would indicate that the Coroner must respond

within this period.

D. THE INQUEST

(i) Initial Listing and Case Management

We were unable to establish if there were any specific issues surrounding case

management and the initial listing of matters however listing and case management is

certainly identified as having a significant impact when inquests are adjourned.32

29 Interview with Margy Wilde-Brown, 23 September 2004 30 Information sourced from a VACC interview with Sgt Peter Bellion, Victoria Police Major Collision Investigation Unit entitled ‘Crash Course’. 31 Interview with senior constable, Homicide Squad, 25 October 2004 32 Interview with Coroner’s Assistant, Coroners Court 28 August 2004.

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(ii) Interested Parties

The number of interested parties involved in an inquest also appears to have some impact

on delays. As the number of interested parties increase so do the number and complexity

of the issues raised and the potential for adjournments during the process.

Inquests may also be adjourned where an interested party, in particular the victim’s

family, is attempting to obtain legal representation at the inquest. Sometimes funding or

pro-bono is sought by the family from organisations such as Legal Aid or PILCH. This

can also contribute to the delays.

Interested parties may also seek adjournments in order to obtain and examine additional

evidence.

(iii) Adjournments to Clarify Issues or Obtain Additional Evidence

Adjournments and the subsequent re-listing of inquests to obtain additional evidence or to

clarify or explore additional issues raised at the inquest clearly have a significant impact

on the delays in the process. Where inquests are adjourned in these circumstances there

are often long periods between the initial hearing and the re-listing of the matter. The

period of time may relate to the extent of investigation required and also to the ability of

the Coroner’s Court to re-list within the existing case management structure.

The ABC program ‘A Case for the Coroner’ aired in 2003 illustrated this issue. During

an inquest into the death of a woman who had overdosed on Quinine, the Court heard

evidence regarding the possibility that the pathology reports at the time of death may

have been incorrect. The matter was adjourned so that blood samples retained could be

re-tested. Although the testing was completed within a short period, the matter was not

re-listed for approximately 6 months. 33

4. CONCLUSION

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The primary cause of delay in the coronial system appears to be by way of investigation

and adjournment.

Accurate fact finding should never be compromised by haste in the investigation stage.

However, while performing these tasks it is important to be conscious of the time taken to

complete the investigation and the effects of this on interested parties such as family

members of the deceased.

Adjournments may be integral to ensuring that the coronial system affords its participants

natural justice. If a party that became interested at a later stage was not given the

opportunity to be heard or represented it would have an adverse impact on the public

interest of accurate fact finding. However, while adjournments are necessary they should

not be granted unreasonably or unconditionally so as to prejudice the interests of other

parties.

(iii)The Investigation:

a. We have been informed that on average approximately 2 years

elapse between death and inquest. Is the time taken for the

police to complete the Brief a reflection of the lack of

availability of resources?

(iv) The Inquest:

a. We note from our enquiries that there are delays at the listing

and re-listing stages. Can case management be improved in

order to reduce the time taken to hand down findings while not

prejudicing the interests of the parties?

33 ‘A Case for the Coroner’ Australian Broadcasting Corporation, Sydney, 2003

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b. We note that interested parties often seek adjournments and

that this results in delay as the matter needs to be re-listed. Can

the number and length of adjournments be reduced in any

way?

c. We note that one of the adverse effects of coronial delays is

that preventable deaths may occur prior to a finding being

made. Can interim recommendations be made earlier so that

more deaths are prevented prior to the final finding being

made?

d. We note that in some instances matters of “public interest” are

informally prioritized in order to deliver quicker findings.

Should matters of broad public interest (according to the

PILCH definition) be formally prioritized in the coronial

process?

i. Should these matters be subjected to an expedited

investigative procedure?

ii. Should these matters take priority in listing in order to

provide quicker findings?

iii. Who would determine which matters are in the “public

interest” and hence their priority?

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5. APPENDIX A Italics – denotes Hallenstein decision all commenced around 1991 and findings all laid down around 1994 Name Death Circumstances Inquest Length Greame Jensen Oct 11 1988 Police Shooting March 1990 17 months Mark Cornish April 2000 Police Shooting ? Heroin Overdoses (40)

1994-1996 Heroin Overdoes

August 1999 3-5 years

Roni Levi June 1997 Police Shooting March 1998 12 months Christopher Dunbar

June 1997 Police Chase June 1998 12 months

Helen Merkle Nov 1995 Police Shooting Oct 1996 12 months Colleen Richman

Sept 1994 Police Shooting Nov 1995 12 months

Fire (Kew Deaths)

April 1996 Fire in home for intellectually disabled

Oct 1996 7 months

Frederick Lewis

November 1995

Police Shooting Nov 1996 12 months

Archie Butterfly

March 1993 Police Shooting May 1996 38 months

Marama Simon August 1995 Police Shooting April 1996 8 months Hai Foong Yap Oct 1988 Police Shooting Dec 1991- July

1994 3 years

James Edward Smith

Dec 1992 Police Shooting July 1994 1.5 years

Norman Leung Lee

? Police Shooting Feb 1995

Gary Abdallah April 1989 Police Shooting Dec 1991 -Nov 1994

2 years

Anthony White July 1990 Police Shooting August 1994 4 years Ian Turner June 1988 Police Shooting Dec 1991- July

1994 3 years

Gerhard Sader Feb 1988 Police Shooting Dec 1991- June 1994

3 years

Arthur Nelson July 1988 Police Shooting Dec 1991-June 1994

3 years

Jed Houghton Nov 1988 Police Shooting Dec 1991-June 1994

3 years

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SEARCH: Inquest and Coroner 672 ARTICLES DEATH NAME CIRCS INQUEST December 2 2002 Mrs Werrick Suicide/Depression March 19 2004 September 2000.

Jason Sidney Bell Police Chase March 19, 2004

November 2000, Freda Cameron wrong medication March 11, 2004 Thursday

New Year's Day 1998

Jaidyn Leskie February 27, 2004

August 18, 2002. Jaxson Heller Baby death February 24, 2004 Tuesday

December 30, 1998. Abubaker Aziz, Pool Drowning February 12, 2004 Thursday

March 10 2003 Thi Huong Giang Huynh

killing her family and herself.

February 3, 2004

December 22, 2000 Viliami Tanginoa Maribyrnong detention centre suicide

November 29, 2003 Saturday

October 19 2002 Isabella Denley Baby death November 26, 2003 September 22 2002 Chad Clay Car explosion –

child death October 11, 2003 Saturday

August 7 last 2002 Sundar Bharadwaj

dead on Lake Mountain

August 19, 2003

November 2000 Cyndy Nguyen, drowned at the Footscray Swim Centre

July 31, 2003 Thursday

May 31, 2000. South Australia's Whyalla Airlines tragedy

July 25, 2003 Friday

October 25, 2001. Christopher Jones, killed at a level crossing

July 16, 2003 Wednesday

February 6 2002 Sam Boulding Asthma death July 10, 2003 Thursday

September 8 2002 Glenn Cuthbert, Speedboat death July 8, 2003 Tuesday

December 19 2002 Clinton McMillan died after being hit by a car

June 24, 2003 Tuesday

February 2002 Peter Crole his four-wheel motorcycle, an all-terrain vehicle, rolled and crushed him


April 6, 2001, Tony Pappa Inexperienced boxer May 2, 2003

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who dreamed of winning a state title died of a brain hemorrhage after a bout

November 11, 2000, Jada Catlin death of a baby girl from suspected meningococcal disease,

April 16, 2003 Wednesday

Boxing Day 2000 Eliana Diskin fed their 51/2-month-old daughter rice milk caused her death

April 8, 2003 Tuesday

February 17, 2000, Georgina Charalambis

collapsed and died during a physical education

February 26, 2003

June 19 2002 John Michael Guglielmino

meningococcal septicemia had taken hold

February 7, 2003 Friday

November 14, 1995 Brent Partridge death of his baby grandson,

February 5, 2003 Wednesday

February 17, 2000,

Alisha Horan. drug and alcohol "bender"

January 3, 2003 Friday

April 28, 2000, Jamie Kirkpatrick accidentally blew air into a lung of a month-old twin with respiratory problems

November 7, 2002 Thursday

October 6, 2000, Frances Tognolini failed heart operation on a five-day-old baby.

October 22, 2002 Tuesday

November 12, 1999 Debra Joy Smeeton's

depression. August 30, 2002 Friday

March 29, 2000. Wade Dunn, 13, overdose of the drug.

August 10, 2002 Saturday

March 18 2001 Antonio Giampietro heart attack July 20, 2002 Saturday

June, 1999 Edward Leslie Hubbard'

A detective training for a Victoria Police elite squad died after losing consciousness during a pool exercise

July 9, 2002 Tuesday

Christmas Day, 2000

Robert Walton Smith

Father Shot With Neighbour’s Arrow

July 3, 2002 Wednesday

23


March 18 2001 Antonio Giampietro died of a heart

attack after Brian D'Sylva struck him and spat at him

July 20, 2002 Saturday

May 2, 1999, Matthew Asahak obstetrician who fractured the skull of a premature baby boy

June 15, 2002 Saturday

June 2000. Heather Jacobs, 48, and her 61-year-old partner, Lindsay Wilson,

gas heater turned the appliance into a "carbon monoxide generator",

June 28, 2001 Thursday

August, 1999.

collapsed after consuming Hoyts Imitation Vodka Essence


December 15, 1997 Dylen Jones became angry with Dylen, who wouldn't stop crying, and struck the back of his head nine times with an open hand.

October 7, 2000

24


6. REFERENCES

‘A Case for the Coroner’ Australian Broadcasting Corporation, Sydney, 2003

Coroner tackles fatal culture of repetition, The Age, 28 October 2004.

Interview with Coroner’s Assistant, Coroners Court 28 August 2004.

Interview with solicitor 11 October 2004. Firm anonymous.

Interview with senior constable, Homicide Squad, 25 October 2004

Interview with Margy Wilde-Brown, 23 September 2004

Dr David Ranson, “The role of the Pathologist in Homicide Investigations and Coronial

Inquiries”, Victorian Institute of Forensic Pathology. www.aic.gov.au/publications/proceedings/17/ranson.pdf

Unit entitled ‘Crash Course’ [Internet – http://www.motor.net.au/VACC/Media/]

State Coroner’s Office Victoria website, The Coronial Process [Internet –

http://www.Coronerscourt.vic.gov.au]

V Pleuckhahn, Ethics Legal Medicine and Forensic Pathology (Melbourne University

Press, 1983) p 9

V Plueckhan, ‘Light at the end of the Forensic Tunnel’ (1986) 60 Law Institute Journal

60, p1059

VACC interview with Sgt Peter Bellion, Victoria Police Major Collision Investigation

25

http://newsstore.theage.com.au/apps/viewDocument.ac?page=1&sy=age&kw=Coroner&pb=age&dt=selectRange&dr=3months&so=relevance&sf=headline&sf=text&rc=10&rm=200&sp=nrm&clsPage=1&docID=AGE041028F27H24T5S8G

http://www.aic.gov.au/publications/proceedings/17/ranson.pdf

http://www/

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