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ANNUAL REPORT OF THE STATE CORONERFINANCIAL YEAR 2011-2012

A report to the Attorney General pursuant to section 39(1) of the Coroners Act 2003 on the administration of the Coroners Court and the provision of coronial services under the Coroners Act 2003.

SOUTH AUSTRALIANCORONERSCOURT

Coroners Court Telephone: (08) 8204 0616302 King William Street Facsimile: (08) 8204 0615Adelaide SA 5000 E-mail: [email protected]

31 October 2012

The Honourable John Rau MPAttorney-GeneralGovernment of South AustraliaGPO Box 464ADELAIDE SA 5000

Dear Attorney-General

In accordance with section 39 of the Coroners Act 2003 I have prepared a report on the administration of the Coroners Court and the provision of coronial services under the Coroners Act 2003 during the financial year ending on 30 June 2012.

The report is forwarded with this letter.

Yours sincerely

Mark JohnsSTATE CORONER

mailto:[email protected]

ANNUAL REPORT OF THE STATE CORONER

TABLE OF CONTENTS

1. State Coroner’s Overview...............................................................12. Acknowledgements.........................................................................43. Reportable Deaths and the Role of the Coroner................................74. Matters Arising During 2011-2012.................................................11

4.1. Senior Research Officer (Domestic Violence).......................................114.2. Odontology Services............................................................................134.3. Comments on Suicide..........................................................................134.4. Staffing Resources...............................................................................144.5. Medical Reports of Death.....................................................................154.6. Hierarchy of Senior Next of Kin............................................................16

5. Statistical Information..................................................................175.1. Cases Reported by NCIS Cause, Manner and Place of Death Code......175.2. Year in Review.....................................................................................18

6. Backlog of Inquests......................................................................197. Professional Presentations of State Coroner and Deputy State

Coroner........................................................................................207.1. 2011 Asia Pacific Coroners Society Conference...................................20

8. Inquests for the Year 1 July 2011 to 30 June 2012...........................228.1. Inquests Held During the Year 1 July 2011 to 30 June 2012.................238.2. Recommendations...............................................................................258.3. Recommendations - Deaths In Custody...............................................348.4. Response to Recommendations - Deaths In Custody...........................37

9. Manager’s Report.........................................................................469.1. Registry Report....................................................................................469.2. Counselling Service..............................................................................479.3. Organ Retention...................................................................................489.4. Disaster Victim Identification...............................................................50

10. Staff Roles and Organisational Chart.............................................51

Annual Report of the State Coroner

Annual Report pursuant to section 39 of the Coroners Act 2003

To the Attorney General

Pursuant to section 39(1) of the Coroners Act 2003 I make the following report to you on the administration of the Coroners Court and the provision of coronial services under the Coroners Act 2003 during the financial year ended 30 June 2012.

1. State Coroner’s Overview

I present the seventh Annual Report of the State Coroner to be tabled in Parliament reporting on the administration of the Coroners Court and the provision of coronial services under the Coroners Act 2003 during the financial year 2011-2012.

The South Australian Coroners Act 2003 provides for the establishment of the Coroners Court and the administration that supports the functions of the Court. The Act defines what constitutes a reportable death, the practice and procedures of the Court, establishes the power of inquiry and of the Inquest and other legal processes that enable the jurisdiction of the Coroner to undertake inquiries and make recommendations.

The Coroners Act provides for the legislative base upon which to investigate the circumstances of a death. Each death reported to the State Coroner requires a level of scrutiny sufficient to establish cause of death and identity. Further to that, each report of the circumstances of a death is the subject of review to a lesser or greater extent. Many people whose deaths are reported to a Coroner, and who require a lesser degree of inquiry, die of natural causes but the death requires reporting to a Coroner because it was unexpected or because the medical practitioner, for whatever reason, is unable to write a certificate of cause of death. Many of these deaths are as a result of lifestyle diseases such as heart disease. The other category of cases that require minimal inquiry is that of the elderly whose deaths are reported because they may be a protected person, had been discharged from hospital within 24 hours of death or because they had undergone a surgical procedure and died within 24 hours or because an incident such as a fall had contributed to their demise.

The majority of reportable cases go on to require further examination sometimes requiring a post mortem examination and police investigation. Such investigations require detailed inquiries including statements from witnesses, reports from specialist agencies, medical practitioners and technical experts. These investigations can take many months and sometimes years to complete. A small number of cases become the subject of an Inquest in Court.

Annual Report of the State Coroner 2011-2012 Page 1

At all stages of the investigation cases are being reviewed. Every death investigation is unique however the Court has established a number of processes that ensures each case is dealt with impartially and fairly according to the principles of the Coroners Act 2003. The major stages of investigation include:

Reports from investigating officers from SAPOL, a statement from a hospital medical practitioner, a report from an aged care facility or institution;

A post mortem examination report; A visual or scientific identification of the deceased; A review of medical case notes, incident reports and forensic medical

reports; A review of specialist reports such as SafeWork SA, ATSB, etc; A review of expert opinion and reports from SAPOL Coronial Investigation

Section.

Once this information has been compiled and assessed the case is recommended to the State Coroner for either finalisation or further investigation. This may require additional reports from experts and analysis from the Coroner’s Counsel Assisting.

Finally, in a case management meeting of a select range of cases, the State Coroner and Deputy State Coroner will determine whether the circumstances of the death are such that it is necessary or desirable that there be an Inquest. Typically such cases relate to public health or safety. When a case meets this criteria the State Coroner and Deputy State Coroner will decide to hold an Inquest (see chart, page 10).

Inquests must be held where the death has occurred in custody. This means a person in custody of the police, a person in prison or home detention, or a person under a detention order as a result of a mental or intellectual disability.

It is not the Court’s role to establish whether a crime has been committed or to find a person guilty of that crime. Nor is it the Court’s role to make judgements about matters of civil liability.

At the conclusion of an Inquest the Coroner will make a Finding which discusses the circumstances of the death as determined by the evidence in Court and, where appropriate, will make recommendations that aim to improve practices and services which may prevent, or reduce the likelihood of, a recurrence of an incident that was similar to the event that was the subject of the Inquest.


The process I have described above is relatively similar in all States of Australia. The ability of a Coroner to influence health and safety practices, public policy and community education cannot, in my view, be underestimated. There is significant interest from the media and the community in general in the matters that come before the Coroner in South Australia. In addition to this there is a growing interest in the jurisdiction from researchers and community groups seeking access to coronial information and data. Whilst the National Coronial Information System is available to service the data requirements of bona fide researchers, my office sees an increasing number of more ‘informal’ community groups requesting access to data, ie. numbers of suicides in particular geographical locations. I regret that I do not have the resources to service such requests. The Coroners Court staffing resources do not include a researcher or a research access officer. Such a resource would be of great assistance to me and the Deputy State Coroner as well as to approved researchers or bona fide community associations.

The Court is required to carry out its work with the resources allocated by Government through the Courts Administration Authority. Savings targets imposed on the latter may or may not, depending on the Authority’s allocation decisions, have an effect on the Coroners Court. As ever, there are pressures flowing from funding decisions to make savings. In an office as small as that of the Coroners Court, even quite modest savings targets have a significant impact. The Court has managed this issue well this year with the help of the Manager, Michele Bayly-Jones, and the excellent staff who support her and the Court. The Court’s work is important and has the potential to enhance public safety. If anything, this work ought to be intensified, not reduced.


2. Acknowledgements

I wish to make special mention of the exceptional work of the Deputy State Coroner, Anthony Schapel. Deputy State Coroner Schapel has undertaken a number of complex and demanding Inquests this year. He has undertaken these duties with dedication and thoughtfulness. I have commented on a number of occasions that his knowledge of the law is exceptional and his ability to apply it to the coronial jurisdiction is scholarly as well as practical - a rare and much admired quality. I simply could not maintain the quality of Inquest Findings if it were not for his considerable legal skills and elegance of written Findings.

My thanks to the three Counsels Assisting the Court over this period, Acting Senior Counsel Assisting Naomi Kereru and Counsel Assisting Amanda Taylor. Ms Taylor completed her contract with the Coroners Court in early 2012 and I thank her for the work she undertook to support the smooth operation of the Court. Amy Cacas returned as Senior Counsel Assisting on a part time basis in April 2012.

The Counsels Assisting both continued their diligent work over the past year and have case managed a high workload. Their advice and counsel to the Deputy State Coroner and me is very much appreciated.

I would particularly like to acknowledge the work of Naomi Kereru who has managed a high Inquest workload this year. Ms Kereru assisted as Counsel on a number of complex matters.

Once again I thank Michele Bayly-Jones, Manager of the Coroners Court, for her unfailing professionalism and dedication. She is available at all hours of the day for the important work of dealing with organ transplant coordination. This is the work of an unsung hero. I commend her for it.

I wish to record my gratitude to the staff of the Coroners Court. Once again they have completed another year of work with their own special brand of dedication to the jurisdiction. They successfully manage a high daily workload and provide me with clear information that enables me to have confidence in the service they deliver to the Court and the community. Again this year I pay tribute to the difficult work they do and to the compassionate manner in which they deal with families.

I can sincerely report that all registry staff are concerned with the wellbeing of recently bereaved families and do all they can to provide a service that is mindful of the constraints of a coronial investigation but also empathetic towards families who are experiencing intense loss and grief. I believe they balance their responsibilities to my role and to the families with a great deal of skill and professionalism.


I acknowledge the endeavours of the SAPOL Coronial Investigation Section to support a quality assured report of death to a Coroner. It is extremely important to receive accurate and detailed reports from SAPOL as their first level report is the one on which we base the need for further inquiries and the SAPOL brief of evidence also provides vital information to the Forensic Pathologist who is undertaking the post mortem. The value of a detailed SAPOL report, that understands the focus and purpose of a coronial inquiry, cannot be underestimated. I thank Detective Senior Sergeant Jeff Brown for his support of the Coroner’s role and his dedication in always working to improve the service and information that SAPOL provides. He has worked to continually improve internal systems and has consulted with other agencies to improve information given in statements to SAPOL officers. Detective Senior Sergeant Brown and his Second in Charge Detective Sergeant (over this period Cameron Georg, Mark McEachern and Jack Fry) are always responsive to requests to follow up further inquiries on cases and continue to provide support and advice to my Counsels Assisting.

I express my thanks to Chief Magistrate Elizabeth Bolton who continues to support the Coroners Court during absences of either Coroners or where cases are not able to be considered by either one of us.

In all coronial jurisdictions the work of the Coroner relies on the skills, knowledge and expertise of other professional groups and, with that in mind, I must acknowledge the work of other Government agencies who contribute to building the knowledge and evidence base of a coronial investigation. In particular I would like to thank Forensic Science SA for their continued excellent work in forensic pathology. All areas of FSSA are attentive to coronial needs and perspectives. The forensic pathologists are always meticulous in the forensic examination of coronial bodies and provide this jurisdiction with thorough reports that include extensive tests and specialist examinations. In many cases the cornerstone of a coronial investigation is the thorough examination of the body and I rely on their advice to guide me in my decision making with regards to further inquiries and, ultimately, the cause of death.

I am proud to report that over many years the Coroners Court and FSSA have shared an excellent relationship. The pathologists are always available to discuss matters with either myself or the Deputy State Coroner and are responsive to the requirements of Counsel Assisting when seeking information about medical matters when reviewing cases and planning Inquests. This level of commitment goes beyond the pathologists as there is similarly a general culture within FSSA which includes the mortuary technicians who liaise with my staff on a daily basis, the scientists and management which is responsive to the coronial jurisdiction.

I thank the Hanson Institute for their work in special brain examinations and in keeping the timeframes for such examinations to a minimum in order to alleviate further worry and distress to families.


I thank IMVS Pathology at Flinders Medical Centre which is the specialist centre for examining hearts in South Australia. I understand that a heart examination is a lengthy process, however I would like to see the timeframes for examination of hearts improved so that my office can give families a reasonably standard timeframe for completion.

My thanks go to the Women’s & Children’s Hospital who, on occasions, perform post mortems on infants and children. I am grateful for their specialised knowledge and expertise in the area of paediatric forensic pathology. The sudden death of an infant or child is always a tragic event and many parents find the requirement for a post mortem intrusive and difficult to understand. However, understanding the reasons why a child has died, or at least in the case of Sudden Unexpected Death in Infancy (SUDI), excluding certain factors for death, is important for a Coroner and can be extremely useful for the parents when coming to terms with the death and in understanding medical implications for other children in the family.


3. Reportable Deaths and the Role of the Coroner

The Coroners Act 2003 requires that the State Coroner investigates all reportable deaths.

The role of a Coroner is to investigate any sudden, unexpected or unknown cause of death. The Coroner establishes the cause of death, the identity of the deceased and inquires into the circumstances preceding the death.

The Coroners Act 2003 provides an interpretation of what constitutes a reportable death. No matter the circumstances of death, the age of the individual or subjective opinion of a third party who may be assessing the death, if the death falls within the definition of a reportable death as defined by the Act, then the death is reportable. There is no discretion to choose whether or not a death is reportable.

The Coroners Act 2003 provides an interpretation on the meaning of a reportable death and that death must be reported to the State Corner where it has occurred: Unexpectedly, unusually or by a violent, unnatural or unknown cause; On a flight or voyage to South Australia; While in custody; During, as a result or within 24 hours of certain surgical or invasive

medical or diagnostic procedures, including the giving of an anaesthetic for the purpose of performing the procedure;

Within 24 hours of being discharged from a hospital or having sought emergency treatment at a hospital;

While the deceased was a ‘protected’ person; While the deceased was under a custody or guardianship order under the

Children’s Protection Act; While the deceased was a patient in an approved treatment centre under

the Mental Health Act; While the deceased was a resident of a licensed supported residential

facility under the Supported Residential Facilities Act; While the deceased was in a hospital or other facility being treated for

drug addiction; During, as a result or within 24 hours of medical treatment to which

consent had been given under Part 5 of the Guardianship and Administration Act;

When a cause of death was not certified by a doctor.

I have stated in previous Annual Reports, and I reiterate, that there is no penalty for reporting a death that ultimately may not be reportable under the Coroners Act, however it is an offence to dispose of the remains of a person


whose death must be reported to a Coroner when such a report has not been made.

In investigating the cause and circumstances of a death I rely on a range of professional opinions. Such opinion may extend to how a practice or system should operate and how practices and systems, if changed, may prevent a death in similar circumstances.

In order to explore these matters I am able to exercise wide powers of inquiry, such as: Entering premises and viewing a body; Inspecting and removing anything pertaining to the coronial investigation; Taking photographs, film, video or other recordings; Remove a body; Exhume a body (with the consent of the Attorney-General) and; To direct a medical practitioner to examine a body and perform any tests

that are necessary to establish the cause of death.

The above powers enable coronial investigators to gather information and provide me with evidence on which to base decisions about whether it is necessary or desirable to hold an Inquest.

Extensive work is undertaken by staff in the Coroners Court, as well as by FSSA and SAPOL to review the circumstances of the death so that the Coroner can receive a recommendation to assess whether a case should proceed to Inquest.

The process of investigating a case from report of death to gathering the necessary information and evidence, and then a decision as to whether to Inquest or finalise the case, can be quite lengthy. The process may take between 9 - 24 months.

Many people believe that all cases reported to a Coroner are the subject of an Inquest. This is not so. On average approximately 2% of the deaths reported to a Coroner in South Australia become the subject of an Inquest in Court. All deaths are investigated to the extent of establishing whether the circumstances of the death warrant the scrutiny of an open Court hearing. When the often lengthy investigations are finalised, the determination usually results in a finding as to the cause of death without a Court sitting or recommendations being made.

Section 25 of the Coroners Act 2003 stipulates that when making Findings upon Inquests, the Court may add to its Findings any recommendation that might, in the opinion of the Court prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the Inquest.


In deciding which cases to present in Court it is Section 25 that provides the benchmark against which to judge the merit of the case and the inherent importance and public interest to the community. It is in this section of the Act that the role of the Coroner and the Coroners Court is truly defined for all who are involved in the investigation, case review process, appearance in Court and the community at large.

However, it must never be forgotten that an Inquest may be extremely beneficial even if no recommendation is made. The holding of an Inquest can shine a light on events that have given rise to public disquiet or concern and provide an occasion for holding people, from all walks of life and stratas of society, to account for the role they may have played in a particular event. The beneficial effects of opening events to public scrutiny, and highlighting events that would otherwise remain hidden from public scrutiny, cannot be overestimated.


South Australian Coronial Process

Stage 1 of processStage 2 of processStage 3 of processNot reportable to Coroner


Report Death to CoronerDeath reported to Coroner, usually by SAPOL, medical practitioners in hospitals, aged care facilities and residential institutions

Coroner determines whether death is reportable (Coroners Act 2003)

Coroners Court Registry Receives reports of death and other relevant information, ie witness statements Initiates family contact and establishes senior next of kin Prepares paperwork for post-mortem, case management and release of body

documentation Prepares correspondence to families, lawyers, hospitals, insurance companies,

etc Court provides information to BDM for death registration purposes

Death is reportable

Coroner may accept medical practitioner’s opinion as to cause of death and ID

Death not reportable under Coroners Act 2003 criteria

Body released to the Funeral Director

Deceased person is under the exclusive control of the Coroner

Coroner may direct a post-mortem (autopsy) examination

Body may be transported to Forensic Science South Australia for post-mortem

Forensic Pathologist provides provisional cause of death to the Coroner

Body released to the Funeral Director

Referred to medical practitioners to issue certificate of cause of death (no further coronial involvement)

Family prepares for funeral arrangements and applies to Births, Deaths and Marriages for a Death Certificate

Investigation Process Final post-mortem report received SAPOL brief of evidence received Other reports (SafeWork SA, ATSB, Major Crime) received Case management meetings with Counsels Assisting and Coronial

Investigation Section

Cause of death accepted and no further issues

If case is subject to criminal prosecution or Industrial Court, the coronial investigation is suspended until completion of those matters

Counsel Assisting Review cases Seek expert technical and medical opinions Case referred to Coroner where Inquest not

required

Finding

Finding

Finding

Counsels Assisting present cases to Coroner to decide whether an Inquest is required (approximately 2% of total cases proceed to Inquest)

Death in custody Inquests are mandatory

Inquest heldAn Inquest is a public Court hearing

Coroner makes a Finding describing cause, circumstance and evidence and may make recommendations

Finding is published on Courts Administration Authority website

4. Matters Arising During 2011-2012

4.1. Senior Research Officer (Domestic Violence)

As reported last year, the position of Senior Research Officer (Domestic Violence) was announced as an election commitment of the State Government in 2010 and is managed through a partnership between the South Australian Coroners Court and the Office for Women.

The position is based primarily in the Coroners Court, however also complements other initiatives of the State Government’s A Right To Safety agenda, such as the Violence Against Women Regional Collaborations and the Family Safety Framework. At a Senior level this position reports directly to the A Right To Safety Chief Executive’s Group which is Chaired by Gail Gago MLC, the Minister for the Status of Women.

On a functional day to day level, this position reports to both the Coroners Court and the Office for Women. I would like to acknowledge the cooperative partnership between this office and the Office for Women.

The relationships which have been built over the past year are mutually beneficial with the Office for Women providing the Coroners Court with briefings and advice regarding the current status of reforms such as the Intervention Orders (Prevention of Abuse) Act 2009 and the Family Safety Framework. In addition, the Senior Research Officer has spent considerable time presenting to various Government and community based representatives regarding the role of this position, the Coronial investigation process and the purpose and reporting of Inquest Findings (refer chart below). Further regional communication is planned for 2012.


2011 – 2012 Communication Summary Chart

Num

ber

of

Part

icip

ants

The role of this position is to research and investigate domestic violence related deaths. The position identifies domestic violence issues, relevant service systems and investigates the adequacy of system responses. This advice forms part of the coronial brief and builds the capacity of the coronial Inquest to explore and inquire into system responses to domestic violence and make recommendations with a preventative focus.

In the past year there has been significant investigation and advice provided to this office regarding deaths which have a suspected background or context of domestic violence. The Domestic Violence position reviews open coronial cases, that is, cases which are under current coronial investigation. The scope of this position is broad and can encompass homicide, homicide-suicide (or multiple deaths) and single instance suicide. The ability to review open coronial cases and the capacity to explore single instance suicide deaths are relatively unique features of Australian Domestic Violence Death review processes as compared with domestic violence death reviews mechanisms operating internationally.

Case Review Summary (as at 30 June 2012)

Status Intent Adult ChildFemal

e Male Female MaleOpen coronial matters marked for review

Assault 4 2 1Intentional Self Harm 3 7 2 2Not yet determined 2 3

Total open matters = 26 9 9 2 6

Closed coronial Assault 3 (*1) 1 *(1)matters - review Death in Custody 2 (*2)complete Intentional Self

Harm 6 17 (*1)

Not yet determined 2 2Total closed matters = 34 9 19 2 4

* number of deaths investigated at a full Coronial Inquest

The identification of cases for domestic violence review is ongoing, however, at the end of this reporting period there were approximately 26 matters identified and awaiting review. A further 34 reviews had been completed with 5 of those deaths being explored further at a full coronial Inquest. The full Findings and recommendations for these Inquests are available on the Coroners Court website.

I would like to identify a specific recommendation made by Deputy State Coroner Schapel in the matter of Hayward and Durance. In May 2011 a preliminary recommendation was made to consider the implementation of the


Family Safety Framework in the Murray Mallee Police local service area. This recommendation was responded to in a timely manner by the entities involved and the Family Safety Framework was established in that region by the end of 2011. Further to this the Family Safety Framework model is now supported and being implemented at a statewide level. This is an example of the outcomes possible through the investigation of matters using a specific domestic violence perspective. Further negotiations have taken place in the past 12 months between this office, the SAPOL and the Child Death and Serious Injury Review Committee to establish information sharing to support and align investigation processes across these three investigation mechanisms.

Another significant outcome of this initiative is the formation of the Australian Domestic Family Violence Death Review Network (ADFVDRN). This Network comprises membership of the other jurisdictions which currently have similar domestic violence death review processes. This is an active and productive network which is working to align definitions, processes and data collection at a national level.

Initially, this position was announced as a 4 year position and I am pleased to report that this position is now ongoing. This enables a continuity of support to coronial processes as well as the capacity for longitudinal analysis and research relating to South Australian deaths with a domestic violence context.

I look forward to reporting further on the outcomes of this position in 2013.

4.2. Odontology Services

I am pleased to report that the State Government has funded the Forensic Odontology Service. In my last Annual Report I was critical of the decision to no longer fund this nationally renowned service. I was concerned that this State would lose the expertise to identify facially traumatised bodies particularly in a disaster situation where multiple identifications could be required. I rely on examination of dental remains when other forms of identification are difficult due to facial trauma or decomposition. The forensic odontology service is efficient, responsive and accurate. I believe that this State should foster and support this expertise and value the skill and dedication of the current team of practitioners who ably provide this service.

4.3. Comments on Suicide

Over the past two years I have commented on the high number of suicides in our community. The highest incidence is amongst males between the ages of 20 to 60 years with the majority of both males and females taking their life at their home addresses.

Last year I reported that there were 202 self harm reports (open and closed cases) of death attributed to suicide. This year I report that the number has slightly decreased to 181 (open and closed cases), however that figure does


not include deaths of single vehicle and single occupant road fatalities, some drug overdose fatalities or suicides in custody.

I continue to take a strong interest in this issue. The Manager of the Coroners Court is a member of the SA Suicide Prevention Strategy Ministers Advisory Committee as chaired by Dr Peter Tyllis, Chief Psychiatrist, Department for Health and Ageing. I am keen to observe the progress of this Committee.

I have publicly spoken on this issue on four occasions during the year under review and I continue to support opportunities where I can contribute to public debate and education about suicide behaviour and consequences. During the year under review I was invited to participate in the following:

Uniting Church Media Discussion - Suicide: It’s No Secret; Journalism Education Association of Australia Annual Conference - Suicide

as News; Minimisation of Suicide Harm (MOSH Australia) Public Forum - Suicide Toll; SA Branch of the Australian and New Zealand Psychiatrists Symposium:

Coronial process in relation to suicide and psychiatric practice in SA.

There are many dedicated people both in the Government and non-Government sectors who are working diligently, strategically and creatively to improve access, support and services for people who are experiencing thoughts and actions of self harm. I commend their efforts.

I encourage any person who is having thoughts of self harm to seek assistance - see a doctor, community support group, family member or friend. There are many people and organisations in our community who want to help and will do everything in their power to reach out to those people who are experiencing their loneliest, angriest, saddest and lowest of times.

4.4. Staffing Resources

Staffing levels have remained the same during the year under review. I congratulate the small staff of the Coroners Court for their continued dedication and hard work. Staff continue to develop improved ways of approaching work within limited resources. They are mindful that any rationalisation or business reengineering processes do not adversely affect the services provided to grieving families. Many of our staff have been here for a number of years which is a testament to their dedication to this jurisdiction, their professionalism in ensuring that the initial investigations are thorough and their desire to assist families who are experiencing sudden and traumatic loss.

I commented last year that certain services may have to be curtailed due to lack of resources. I am pleased to report that due to proactive staff management of their duties, the waiting times have not increased to an alarming level. As I previously mentioned, staff attempt to manage the workload so it does not adversely affect families in an unacceptable manner.


The issue of staffing resources does impact on the rate at which Counsels Assisting can review cases and present them for Inquest. We only have enough resources to deliver the current number of Findings from Inquest per year. This number consistently hovers between 30-35 Findings delivered each financial year. I suggest there is no capacity to increase this level of output within current resources.

4.5. Medical Reports of Death

Work has been done this year with Risk Managers from public hospitals, the Officer in Charge of the Coronial Investigation Section, the Manager of the Coroners Court and Senior Counsel Assisting the Coroner in developing a protocol for police requests for information from staff of a health care facility when a patient has died. I report that the process of obtaining statements from medical staff has improved.

I have been concerned during the year under report about the process of medical practitioners in hospitals completing the ‘Coroners Medical Deposition of Report of Death’ form. This form is distributed from the Coroners Court to the medical practitioner to complete when a patient death is reportable. The purpose of the form is as a statement from the treating practitioner to the Coroner giving details of the patient’s medical history, presenting medical issue, treatment rendered and opinion as to the cause of death. My expectation is for this form to be completed by a senior medical practitioner who treated the deceased. Over the past year both the Deputy State Coroner and I have noticed that the task of completing this form has often been delegated to a junior doctor who may not have the detailed clinical knowledge or overview that a senior practitioner or consultant would have. This form should not to be used as a training tool for junior medical practitioners. It is a formal statement to the State Coroner and should be completed by the most knowledgeable person who treated the patient during the time in hospital prior to death.

In years past this statement was obtained verbally over the phone by a Coroners Court staff member who transcribed the doctor’s statement word for word and then faxed the statement back to them for corrections and signing. This process was time consuming and difficult for the doctors involved. The introduction of the medical deposition form was welcomed by both the Coroners Court staff and the medical staff. I would not like to have to reintroduce the system of taking a statement by phone simply because the appropriate medical staff would not take the time to complete the Medical Deposition form.

Having said that, I would like to acknowledge those few doctors who do take the time and responsibility and complete this form thoroughly and professionally. A well documented medical deposition form can avoid the need for a post mortem and assist in assessing the circumstances of the


death and speed up the process of returning the deceased to his or her family’s funeral director.


4.6. Hierarchy of Senior Next of Kin

The Coroners Court Rules 2005 provide an interpretation for ‘senior available next of kin’ and is as follows:

Senior available next of kin means-(a) in relation to a child, the first in order of priority of the following persons

whose contact details are known to the Manager:

(i) a parent of the child;(ii) a brother or sister, who has attained the age of 18 years, of the child;(iii) a guardian of the child; and

(b) in relation to any other person, the first in order of priority of the following persons whose contact details are known to the Manager:

(i) the spouse of the person;(ii) the de facto partner of the person;(iii) a son or daughter, who has attained the age of 18 years, of the

person;(iv) a parent of the person;(v) a brother or sister, who has attained the age of 18 years, of the

person.

Spouse includes putative spouse (Coroners Court recognises this as having a defacto relationship of co-habitation of 2 years and/or parents of biological children).

This interpretation refers to Division 2 – Inquests in the Coroners Court Rules and applies to the service on relatives of notice of intention to hold an Inquest.

It is a matter of policy that the Coroners Court also applies the hierarchy of ‘senior available next of kin’ to requests for access to information and approval to access items such as tissue samples for DNA testing.

In most instances this policy is acceptable to families who wish to keep such matters private. It also stops Coroners Court staff from having to explain the coronial process to every family member who seeks information or explanations about complex processes. The practice is to recognise one or two family members as the senior next of kin or spokesperson and provide them with all of the information and correspondence. No other family members are eligible to receive information about the coronial investigation without the written permission of the listed senior next of kin.

On occasions, particularly where there are family disputes, lack of cooperation and breakdowns in communication, family members are unhappy with the application of this policy. We try, wherever possible, to encourage families to talk with each other and reach agreements about access to information but


sometimes the family dispute is bitter and no amount of our ‘goodwill’ can bring the parties together. It is not the Coroner’s role to arbitrate in matters of family dispute and breakdown, nor does the Court have the social work resources to devote to mediating such disputes. Hence, the hierarchy of ‘senior available next of kin’ policy is applied without exception.


5. Statistical Information

There was a slight decrease in the number of deaths reported to the State Coroner during the year under review compared to the previous year.

There were 12 723 deaths registered with the Registrar of Births, Deaths and Marriages. This also represents a slight decrease compared to last year. Of those, 2088 deaths were reported to the State Coroner.

There were 44 Inquests held into individual deaths in the 2011–12 year, of these 22 were deaths in custody matters. Of these 44 Inquests there are three matters which are part-heard and will continue sitting in the 2012–13 financial year. There were 9034 pages of transcript produced.

The number of Inquest Findings (41) represents an increase when compared to 2010–11. There was a slight decrease in the number of Court sitting hours (343) compared to 360 in 2010–11.

During the year under review four Inquests were held in a country region, those being Kangaroo Island, Ceduna, Port Augusta and Port Lincoln.

5.1. Cases Reported by NCIS Cause, Manner and Place of Death Code

Cause Deaths Cause Deaths

Aircraft 5 Industrial Accident 6Aspiration of Vomitus 6 Marine 0Burns 2 Natural 590Death in Custody 20 Other 21Death in Institution 265 Pending Post-Mortem 79Dehydration 1 Petrol Sniffing 0Disease 0 Poison 3Domestic Accident 8 Refer back 0Drowning 11 SIDS 1Drug Overdose 70 Skeletal Remains 0Fall 13 Suicide 181Homicide 20 Undetermined Cause 34Hospital 647 Vehicle Accident 106House Fire 4


5.2. Year in Review

During the year under review 2088 deaths were reported to the State Coroner and 2470 cases were finalised (closed cases includes cases that were opened in previous years).

At A Glance 2008-09

2009-10

2010-11

2011-12

Number of Coroners 2 2 2 2Number of Staff 17 16.5 16.5 16.7*Number of deaths reported 2099 1929 2148 2088Number of post mortems 1571 1242 1146 1005Inquest findings delivered 33 31 33 41Number of Court sitting hours 339 532.5 360 343

*One Senior Counsel Assisting commenced at .6FTE on 23 April 2012.

*2011-12 FTE numbers includes locum social workers.


6. Backlog of Inquests

As at 30 June 2012 there were 31 Inquests awaiting hearing in the Coroners Court, including 21 cases involving a death in custody. This number is an identical number to the previous year. There were 1194 open cases pending inquiry. This is a significant decrease when compared to the previous year. These cases are at varying levels of investigation. Some may progress to a review by Senior Counsels Assisting the State Coroner and the Coronial Investigation Section (a unit within South Australia Police, often referred to as 'coronial police').

Of the total pending caseload there is a backlog of 24.6% of cases that are open for investigation for longer than 12 months. This is a 2.9% decrease on last year’s position. Of the total pending caseload there is a backlog of 10.6% of cases that are open for investigation for longer than 24 months. This is a 1.9% increase on last year’s position. Cases open for longer than 24 months include those cases being investigated by SafeWork SA and Major Crime, or have cases pending hearing in another Court.

As at 30 June 2012 Senior Counsels Assisting had 67 cases under high-level investigation with an additional 22 cases under investigation by coronial police.


7. Professional Presentations of State Coroner and Deputy State Coroner

State Coroner

Member SA Indigenous Justice Committee

Presentations Legislative Review Committee – Inquiry into Stillbirths International Conference for Emergency Nurses – Keynote Speaker Royal Adelaide Hospital Emergency Department Staff - Role of the Coroner SAPOL - Detective’s Course (Multiple Sessions) St Anns College, North Adelaide – Joint Presentation to Students with FSSA

Deputy State Coroner

Member CAA Community Relations Committee

Presentations Legislative Review Committee – Inquiry into Stillbirths SAPOL – Inspectors Qualification Course Law Society – Graduate Diploma, Legal Practice, Course in Advocacy

(Multiple Sessions)

7.1. 2011 Asia Pacific Coroners Society Conference

The 2011 Asia Pacific Coroners Society Conference was held in Queensland. The theme of the conference was ‘Australasian coronial systems 20 years after the Royal Commission into Aboriginal Deaths in Custody: achievements and challenges’.

The conference aimed to reflect on what has been achieved and what challenges remain 20 years after the RCIADIC reports provided the insightful analysis on the issues relating to the incarceration of indigenous people. To that end there were presentations that provided an analysis of what existed at the time of the Commission and how the coronial Inquest provided a platform for examining systems and making recommendations that focussed Governments on facilitating changes and law reform. The speakers also addressed the issue of Aboriginal suicide in custody.

The Western Australian State Coroner, Alistair Hope, spoke about his Inquests into Aboriginal deaths in the Kimberley which included 17 deaths by suicide and the 2008 Inquest into the death of an Aboriginal man who died in the rear pod of a prison van from the effects of heat and dehydration.


Focussing on this issue also enabled the delegates to assess the impact of the Royal Commission on non-Aboriginal deaths in custody. These presentations were equally relevant to Coroners, their staff, police officers and forensic pathologists.

Later in the conference the program turned to discussing the merits of the external autopsy, the impact of coronial recommendations on safety improvements, and the theories of expert evidence and the multi-agency investigation.

The conference concluded after presentations on the topics of suicide after natural disasters and lessons from the Christchurch earthquake disaster.


8. Inquests for the Year 1 July 2011 to 30 June 2012

Aufiero, Sonia Lidia Austin, Dallas Dixon Baker, Neville Ronald Balnaves, Craig Henri Bellocco (Aka Ieva),

Carmelina Bugg, Linda Edith Butler, Mark Andrew Davis, Tracey-Lee Dickerson, Alexander

Charles Eddleston, Bryce Ashton Edgar, Lauren Michelle Fell, Michael Terence Ferme, Susan Jane Gibson, Kunmanara Gill, Dennis William Greenhalgh, Kym Charles Gripton, William John Heyward, Neil Willis Hocking, Robert Hollonds, Andrew David Johnson, Peter Andrew Jolly, Rebecca Anne Penfold

Kavanagh, Tully Oliver Kison, Trinity Isabel Kruger, Mary Patricia Kugena, Kunmanara (male) Kugena, Kunmanara (female) Lambert, Judith Ann May, Terrill Anthony Minning, Kunmanara Mumford, Michael John Paxton, Donald Henry Peters, Kunmanara Polklaser, Irmgard Giesela Proctor, Janis Mary Radford, Roger Gordon Ricci, John Peter Robinson, Shane Andrew Smith, Norman John Ebanezer Swavley, Matthew Tyson Sweetman, Amber Jayne Thalbourne-Maitreya, Michael

Anthony Weeks, Ronald Geoffrey Windlass, Kunmanara

** Italics denote that the matter is part heard and will resume in the 2012/2013 financial year.


8.1. Inquests Held During the Year 1 July 2011 to 30 June 2012

No Name Date of Death

Inquest Number

Inquest Start Date

Finding Delivered

Period (mths) From DOD

Period (mths) From

Inquest1 KUGENA, Kunmanara (female) 27/02/04 16/2011 14/07/11 04/11/11 94 42 WINDLASS, Kunmanara 17/04/05 16/2011 14/07/11 04/11/11 80 43 PETERS, Kunmanara 03/09/05 16/2011 14/07/11 04/11/11 75 44 KUGENA, Kunmanara (male) 20/11/05 16/2011 14/07/11 04/11/11 73 45 GIBSON, Kunmanara 14/07/09 16/2011 14/07/11 04/11/11 28 46 MINNING, Kunmanara 05/10/09 16/2011 14/07/11 04/11/11 25 47 WEEKS, Ronald Geoffrey 20/09/09 20/2011 29/07/11 - - -8 SWAVLEY, Matthew Tyson 16/10/09 21/2011 18/08/11 22/12/11 27 49 SWEETMAN, Amber Jayne 18/02/09 22/2011 09/08/11 26/03/12 38 810 PENNIALL, David 04/03/09 23/2011 28/06/11 09/05/12 39 1111 BALNAVES, Craig Henri 09/05/09 24/2011 08/07/11 - - -12 JOHNSON, Peter Andrew 14/09/09 25/2011 15/07/11 - - -13 DAVIS, Tracey-Lee 08/07/09 26/2011 20/07/11 - - -14 GILL, Dennis William 30/08/09 27/2011 03/08/11 03/08/11 23 015 PAXTON, Donald Henry 08/10/09 28/2011 12/08/11 12/08/11 22 016 XU, Yan Yi 28/12/08 29/2011 13/10/10 26/08/11 32 1117 GRIPTON, William John 13/05/08 30/2011 29/08/11 18/06/12 50 1018 FERME, Susan Jane 29/04/07 31/2011 17/08/11 19/09/11 53 119 KISON, Trinity Isabel 28/10/08 32/2011 20/09/11 - - -20 JOLLY, Rebecca Anne Penfold 11/01/10 33/2011 12/09/11 10/05/12 28 821 GREENHALGH, Kym Charles 01/04/08 34/2011 26/09/11 - - -


No Name Date of Death

Inquest Number

Inquest Start Date

Finding Delivered

Period (mths) From

DOD

Period (mths) From

Inquest22 BELLOCCO, Carmelina 16/10/09 35/2011 08/09/11 20/09/11 23 023 MAY, Terrill Anthony 03/04/09 36/2011 25/10/11 - - -24 EDGAR, Lauren Michelle 10/03/08 37/2011 21/11/11 - - -25 MUMFORD, Michael John 26/12/09 38/2011 01/11/11 - - -26 RADFORD, Roger Gordon 05/12/09 39/2011 03/11/11 - - -27 POLKLASER, Irmgard Giesela 15/08/10 40/2011 10/10/11 25/06/12 23 928 BUTLER, Mark Andrew 04/07/09 41/2011 21/10/11 - - -29 AUFIERO, Sonia Lidia 30/12/09 42/2011 29/11/11 - - -30 FELL, Michael Terence 30/12/09 42/2011 29/11/11 - - -31 ROBINSON, Shane Andrew 09/07/09 43/2011 24/11/11 - - -32 BUGG, Linda Edith 24/10/09 44/2011 22/12/11 - - -33 KAVANAGH, Tully Oliver 09/10/11 45/2011 25/10/11 06/12/12 14 1434 AUSTIN, Dallas Dixon 04/12/09 46/2011 18/11/11 - - -35 KRUGER, Mary Patricia 06/03/08 47/2011 13/12/11 - - -36 PROCTOR, Janis Mary 22/02/08 02/2012 03/04/12 13/04/12 50 037 HOLLONDS, Andrew David 19/11/09 03/2012 20/04/12 - - -38 LAMBERT, Judith Ann 16/02/10 04/2012 03/07/12 - - -39 DICKERSON, Alexander Charles 21/03/10 05/2012 16/05/12 - - -40 EDDLESTON, Bryce Ashton 24/02/10 06/2012 05/06/12 - - -41 HOCKING, Robert 17/02/10 08/2012 04/06/12 - - -42 BAKER, Neville Ronald 18/02/10 09/2012 04/06/12 - - -43 RICCI, John Peter 25/04/10 10/2012 20/06/12 - - -44 THALBOURNE-MAITREYA, Michael

Anthony 04/05/10 11/2012 26/06/12 - - -45 SMITH, Norman John Ebanezer 07/05/10 12/2012 27/06/12 - - -


8.2. Recommendations

Section 25(2) of the Act provides that the Court may add to its findings any recommendations that might, in the opinion of the Court, prevent or reduce the likelihood of a recurrence of an event similar to the event that was the subject of the Inquest. Where a recommendation is made pursuant to section 25, the recommendation must be included in this annual report (section 39(2)). The following is a list of recommendations made by the Coroners Court during the year the subject of this report (excluding deaths in custody):

Bais, Jamie Stuart (Coroner Schapel)

In the light of the material that has been placed before the Court regarding change, I need only make the following recommendations. I recommend that the Minister for Health bring to the attention of the Chief Executive Officer of all public hospitals the Flinders Medical Centre protocol of March 2010 relating to ENT patients with suspected meningitis. I further recommend that the Chief Executive Officers of all public hospitals give consideration to the issue as to whether such a protocol should be employed in each such hospital.

Ballard, Margaret Dawn (Coroner Johns)

It would appear that the Mental Health Directorate has recognised the lessons to be learnt from, not only Mrs Ballard’s case, but those other cases which were the subject of the Root Cause Analysis. I recommend that the Minister for Health note this Finding and endorse the recommendations of the Root Cause Analysis, Exhibit C19.

Burns, John Arthur (Coroner Johns)

Associate Professor Whitehead very helpfully provided, for the benefit of the Court, a publication dated November 2008 of the Drug and Therapeutics Information Service ‘DATIS’, which is a continuing medical education initiative of the Pharmacy Department of the Repatriation General Hospital, Daw Park, South Australia. The DATIS review was admitted as part of Exhibit C30a and is a comprehensive review of management of dementia in general practice with a focus on cognition and behaviour. In particular, it contains a comprehensive discussion about the effects of antipsychotic medication on mortality in dementia patients. I commend the review to the attention of medical practitioners in general practice who regularly manage dementia patients, particularly in nursing home settings and I recommend that the Minister for Health take such steps as are necessary to draw the DATIS review to the attention of such practitioners.

Ferme, Susan Jane (Coroner Johns)

I recommend that the Department of Health reissue instructions to all medical staff working in country hospitals that:

a) The requirements and protocols set out within the ICCnet1 SA Management of Chest Pain/Suspected Acute Coronary Syndrome Guideline2 should be strictly adhered to

1 Integrated Cardiovascular Clinical Network2 Exhibit C9


and, in particular, that staff should be directed to strictly adhere to the requirements of the low risk protocol and;

b) That regardless of whether the low risk protocol criteria are satisfied, medical staff should only discharge patients where there is in existence an alternative explanation for their chest pain and where that explanation has a high degree of certainty.

Gripton, William John (Coroner Johns)

I recommend that the Department of Health support the continuation of the work of the Deteriorating Patients Steering Group with a view to the implementation of systems for the detection and subsequent management of deteriorating patients3.

Hillman, Glenys Anne and Leonard, Emily Ruth (Coroner Schapel)

This Finding was the subject of an appeal to the Supreme Court of South Australia. See Onuma v The Coroner’s Court of South Australia [2011] SASC 218. This Finding was affected by orders of the Supreme Court and should be read in conjunction with the decision of the Supreme Court.

I make the following recommendations:

1) That the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) consider promulgating a requirement that members and Fellows of the College who profess to have the competence to perform, and who do perform, abdominal vaginal prolapse surgery of the kind with which this Inquest is concerned, demonstrate to the College that they have the necessary training, experience and competence to perform such surgery safely and that they demonstrate this by way of examination. Such a demonstration should include convincing evidence that the practitioner is able competently to perform a proper risk assessment in respect of the nature of the surgery to be performed that should include consideration of risk posed by the presence, or potential presence, of adhesions within the abdomen and consideration of whether a drain should be placed following abdominal surgery, particularly where diathermy has been used to divide adhesions. The practitioner should also be required to demonstrate that he or she has the necessary skill to competently perform the repair of an injured bowel if necessary;

2) That RANZCOG consider promulgating a requirement that members and Fellows of the College who profess to have the competence to perform, and who do perform, abdominal vaginal prolapse surgery of the kind with which this Inquest is concerned, obtain a Certificate of Urogynaecology from RANZCOG;

3) That the Australian Health Practitioner Regulation Agency and the Australian Medical Association (SA) draw these findings and recommendations to the attention of the wider medical profession.

Jorkowski, Natassja Alexandra (Coroner Johns)


1) I recommend that the Chief Psychiatrist of South Australia consider this finding and the views of Professor Goldney;

3 Exhibit C9a and Transcript, pages 288-290


2) I recommend that the Assessment and Crisis Intervention Service develop a risk management framework which would enable outlying cases such as Natassja’s to be identified with a view to fast tracking a psychiatric assessment in such cases.

Miller, Allan Kenneth (Coroner Schapel)

I recommend that these findings be drawn to the attention of the General Manager of the Royal Adelaide Hospital with a view to that person examining the issue as to whether or not, if a repetition of the circumstances in this case should occur, immediate anaesthetic services could be provided to a patient such as Mr Miller.

Penniall, David (Coroner Johns)

I recommend that the Chief Executive of the Department of Health reinforce with all public hospitals the importance of discharge summaries in mental health cases, particularly where there has been a suicide attempt, and to ensure that notification of such incidents be made to primary health practitioners within 48 hours of discharge.

Polklaser, Irmgard Giesela (Coroner Johns)


1) That the Minister for Business Services and Consumers issue warnings to shoppers about the risks involved in travelling with trolleys on travelators;

2) That the Minister for Industrial Relations ensure that supermarkets are reminded of the importance of properly maintaining their trolley fleet. The evidence in this case of the frequency of events involving trolleys is disturbing. It should not happen at all, and certainly not as frequently as the evidence in this case shows at one shopping centre;

3) That the Minister for Industrial Relations undertake an audit of all available CCTV footage to determine the frequency of this kind of event at all shopping centres in the State to determine if it is necessary to take action by regulation, inspection or other form of government intervention in this area.

Proctor, Janis Mary (Coroner Schapel)


1) That the Minister for Health and Ageing cause to be drawn to the attention of the Chief Executive Officers of all public and private hospitals in South Australia these findings;

2) That consideration be given by persons in authority in hospitals and aged care facilities to the introduction of a risk assessment analysis structure in respect of appropriate showering regimes of patients and residents.

Semmler, Howard Malcolm (Coroner Schapel)


1) That the Australian Health Practitioner Regulation Agency draw to the attention of the medical profession and the podiatry profession the need to medically review and re-evaluate the diagnosis of foot ulcers that fail to heal within an expected time frame;


2) That the Australian Health Practitioner Regulation Agency and the Australian Medical Association (SA) draw this matter to the attention of the wider medical and allied health professions for the purposes of education;

3) That the Minister for Health and the responsible person at the Modbury Hospital give consideration to establishing a multi-disciplinary clinic, such as those that exist in the Lyell McEwin Hospital, the Royal Adelaide Hospital, the Queen Elizabeth Hospital and the Flinders Medical Centre, that is designed to manage, treat and properly diagnose foot ulcers in a timely manner;

4) That the Minister for Health give consideration to the establishment of the role of a ‘patient advocate’ within the public health system to promote better communication between patient’s family members and clinicians and to avoid tension between the wishes of a patient’s family members and the clinical opinions and judgments made by medical practitioners responsible for the patient’s management.

‘Sleeping Rough’ Inquest (Coroner Schapel)

Taking all of the evidence into account as well as counsel’s submissions, I make the following recommendations which I direct to the following entities: South Australian Minister for Health; Chief Executive Officer of the Department of Health; Chief Executive Officer of Housing SA; Regional Manager for Housing SA in relation to the Eyre and Western area; Executive Director of Drug and Alcohol Services, South Australia; Executive Officer, Director of Nursing of the Ceduna Hospital; Chief Executive Officer of the Ceduna Koonibba Aboriginal Health Service; Members and delegates of the Ceduna Senior Officers Group; Officer in Charge, SAPOL Far North Local Service Area; Commissioner for the Office of the Liquor and Gambling; Manager of the Indigenous Coordination Centre, Ceduna (Australian Government); State Manager (SA) of the Commonwealth Department of Health and Ageing; South Australian Minister for Aboriginal Affairs and Reconciliation; Federal Minister for Health and Ageing; Federal Minister for Indigenous Health.

1) That the Commonwealth, State and relevant local Governments recognise that chronic ill health and alcohol abuse poses a serious threat to the wellbeing and functionality of traditional Aboriginal communities and that it poses specific threats to the health and longevity of the individual members of those communities;

2) That the Commonwealth, State and relevant local Governments recognise that the threat to the health, wellbeing and functionality of the members of these Aboriginal communities is a reflection of the extreme social disadvantage that occurs within those communities;

3) That the Commonwealth, State and relevant local Governments recognise that in the Ceduna township and environs there has been, and still is, an ongoing need to reduce the supply of alcoholic liquor to transient Aboriginal populations;


4) That the Commonwealth, State and relevant local Governments recognise that in the Ceduna region there is a need to strengthen and promote amongst the Aboriginal community primary healthcare, housing opportunities, education, literacy and employment;

5) That the Commonwealth, State and relevant local Governments recognise that there is a need amongst the transitional Aboriginal communities, and the members of those communities, to have meaning in their lives such as might be provided by full employment and the pursuit of recreational and educational activities so as to provide those members of the community with a disincentive to abuse substances, particularly alcohol, and to prevent and minimise the incidence of relapse among rehabilitated individuals;

6) That the Commonwealth, State and relevant local governments remind themselves of the Recommendations of the Royal Commission into Aboriginal Deaths in Custody relating to the abuse of alcohol and other drugs (set out in Appendix A herein), many of which continue to have current relevance;

7) I make the following specific recommendations:a) That the Wangka Wilurrara Transitional Accommodation Centre in Ceduna,

otherwise known as the Town Camp, continue to be maintained as an accommodation centre for transient Aboriginal persons. I further recommend that strict enforcement in relation to the possession and consumption of alcoholic beverages on site be maintained;

b) That the Yalata and Oak Valley communities for the time being continue to be dry and that the possession and consumption of alcohol in those communities continue to be prohibited;

c) That supply of alcohol to members of transient Aboriginal communities in Ceduna be reduced by employing one or both of the following strategies:

i) Prohibiting within the region the sale of certain identified kinds of alcohol including fortified wines such as port in casks, as well as cask wine;

ii) That greater resources and effort be provided to address the supply and sale of alcohol to transient Aboriginal people in Ceduna and remote communities of Yalata and Oak Valley;

d) That a declared sobering up centre pursuant to the Public Intoxication Act 1984 be established in Ceduna such that:

i) The declared sobering up centre is sufficiently resourced to accommodate at least 15 individuals;

ii) That it be situated in close proximity to the Accident and Emergency Department of the Ceduna Hospital and preferably be housed within the same building;

iii) That it be staffed and be situated so as to promote efficient interaction between the staff of the sobering up centre and the clinical staff of the Ceduna Hospital, and in particular to better promote and facilitate the


detoxification and withdrawal treatment of persons attending the sobering up centre either voluntarily or those under apprehension pursuant to the Public Intoxication Act 1984;

iv) That the sobering up centre be sufficiently staffed and resourced so that it can remain open and receive patients at all times;

v) That it have the capability as required under the Public Intoxication Act 1984 to detain patients in a secure and therapeutic environment for the statutory period of time stipulated under the Public Intoxication Act 1984, namely 18 hours;

vi) That the sobering up centre be regarded by police as the option of first resort upon apprehending a person pursuant to section 7(3) of the Public Intoxication Act 1984 where detention of the person is believed to be necessary and desirable;

e) That the Executive Director, Director of Nursing of the Ceduna Hospital continues to develop strategies that engender within the hospital a culturally appropriate environment with a view to inducing Aboriginal patients to remain in hospital until such time as their treatment has been completed;

f) That the recommendations made by Dr David Scrimgeour AM, as set out within these findings, be implemented, namely:

'I would recommend that Ceduna Hospital develop an agreement with the Ceduna Sobering Up Shelter to ensure that medically supervised detoxification is available to people referred from the Sobering-Up Shelter when required. I would recommend the development of a strategy for the management of alcohol addiction in the Ceduna area, involving all health services including the hospital. Such a strategy should include a plan about who should be notified if a patient with a known alcohol problem discharges himself or herself against medical advice, to maximise the chances of ongoing medical and social support. I would recommend that appropriate and sufficiently-resourced alcohol rehabilitation facilities be established within the vicinity of Ceduna, Yalata and Oak Valley as a priority. I would recommend that ongoing counselling services be available to support the management of alcohol addiction. I would recommend that ongoing training and support be provided to general practitioners and other primary health care personnel in Ceduna, particularly at Ceduna Koonibba Aboriginal Health Service, to up-skill them in the medical management of alcohol addiction. ' 4

g) That an alcohol rehabilitation centre or facility be established that possesses the following elements, namely:

i) That it be established at a location on the west coast;

4 Exhibit C87a, page 4


ii) That it be situated sufficiently close to the Aboriginal communities who would utilise it on the west coast;

iii) That the rehabilitation centre, wherever situated, engages with and is culturally sensitive to members of the Aboriginal community;

iv) That it be situated well away from licensed establishments and other sources of alcohol;

h) That the South Australian legislature consider enacting legislation that would provide for the mandatory detention and treatment of persons with severe substance dependence, particularly if an alcohol rehabilitation facility were to be situated at Port Augusta or at some other location in close proximity to licensed premises or other suppliers of alcoholic beverages.

Spencer-Koch, Tate and Hobbs, Jahli Jean and Kavanagh, Tully Oliver (Coroner Schapel)


Directed to the Minister for Health

1) That the Minister bring into operation section 10 of the Health and Community Services Complaints (Miscellaneous) Amendment Act 2011 which would insert within the principal Act a new Part 6 Division 5, and in addition introduce legislation that would render it an offence for a person to engage in the practice of midwifery, including its practice in respect of the management of the three stages of labour, without being a midwife or a medical practitioner registered pursuant to the National Law;

2) That the Minister consider introducing legislation that would impose a duty on any person providing a health service, including midwifery services, to report to the South Australian Department of Health and Ageing the intention of any person under his or her care to undergo a homebirth in respect of deliveries that are attended by an enhanced risk of complication, for example but not limited to, homebirths involving the birth of twins or known breech birth at term;

Directed to the CEO of the South Australian Department of Health and Ageing

3) That upon notification of a person’s intention to undergo a homebirth attended by an enhanced risk, that the Chief Executive Officer of the South Australian Department of Health and Ageing cause advice to be tendered to that person from a senior consultant obstetrician as to the desirability or otherwise, in the circumstances of the particular case, for a homebirth to be conducted;

Directed to the Minister for Health and the CEO of the South Australian Department of Health and Ageing4) That consideration be given to the establishment of a position known as the

Supervisor of Midwives based upon the position described as such in the United Kingdom;


5) That consideration be given to the establishment of alternative birthing centres as contemplated by the Australian Medical Association (South Australian Branch). I here refer to the evidence of Dr Lavender at T741-743 in the Inquests re Tate Spencer-Koch and Jahli Hobbs.


Directed to the CEO of the South Australian Department of Health and Ageing6) That education in the form of written advice distributed generally to the public be

provided in respect of the following matters concerning homebirths:a) The risks associated with certain types of birth, including but not limited to, twin

births and breech births;b) How those risks might be affected by a choice to undergo such deliveries within

the individual’s home;c) To dispel the notion that adverse outcomes in homebirthing cases would

inevitably have occurred in a hospital setting in any event;d) To dispel the notion that the second born of twins would inevitably be the subject

of immediate intervention following the delivery of the first twin;e) As to the need and desirability of epidural pain relief and whether such is

mandatory or not in certain birthing environments within a hospital;7) That the revised policy for Planned Birth at Home in South Australia be brought into

operation, with an addition that current risk factors for shoulder dystocia be specifically identified;

8) That in any case where it comes to the attention of clinicians in a public hospital that a patient intends to undergo a homebirth that is attended by an enhanced risk of complication, that appropriate advice be tendered to that person by a senior consultant obstetrician.

Sweetman, Amber Jayne (Coroner Schapel)


1) That the Minister for Health cause to be expedited the digitisation of radiological imagery at the Women's and Children's Hospital;

2) That the Minister for Health cause to be expedited the implementation of the centralised digital system of storage of radiological imagery available for access by all public hospitals in South Australia;

3) That these findings be drawn to the attention of the wider medical profession, including but not limited to general practitioners, emergency clinicians and paediatric, neurological, neurosurgical and radiological trainees. I direct this to the attention of the Minister of Health, the principal administrative officers of all South Australian medical schools and the South Australian Board of the Medical Board of Australia through the Australian Health Practitioner Regulation Agency.

Tilka, Susan Marie (Coroner Johns)

A number of protocols were produced in the course of the Inquest. I agree with counsel for Associate Professor Young that the protocols produced in this Inquest would benefit by a more prominent reference to bleeding as being a warning sign, in certain circumstances, of a catastrophic bleed and a trigger to ward nurses to engage with the intensive care equipment nurse to discuss that possibility.

I therefore recommend that the relevant protocols be reviewed to point out to ward nurses the potential for bleeding to be significant.


Associate Professor Young was clearly of the view that all nurses in wards who are looking after tracheostomies should complete the educative workbook (Exhibit C8g) entitled ‘Principles for Basic Tracheostomy Management Workbook’ and I recommend accordingly.

As noted by counsel for Associate Professor Young, there is only one question raising the matter of bleeding in the workbook where the workbook asks:

'After performing tracheal suction you notice the tracheal aspirate is blood stained. What action would you take?'

I recommend that the workbook be modified to raise the issue of blood appearing in circumstances other than the tracheal aspirate.

The above recommendations are directed to the Minister for Health.

Wyatt, Jakob James and Wyatt, David James (Coroner Johns)


1) That the licensing system under the Criminal Law consolidation Act should be altered so that the responsibility for determining the existence of a breach of a licence condition is reposed in the Parole Board rather than the sentencing Court;

2) That the system under that Act should be altered to permit the incarceration of a licensee within the prison system, notwithstanding that they were not originally convicted of any offence;

3) That licensees detained for breach of a licence condition should be kept in a prison for a period fixed by the Parole Board in order to demonstrate to the licensee that a breach of a licence condition will be visited with an effective sanction;

4) That the relevant Ministers of Agencies party to the Family Safety Framework, note their responsibility to have operational capacity to utilise the FSF mechanisms from all parts of their Agency and across all disciplines within the agency. This is particularly relevant in large Agencies which may have a broad portfolio of multi-disciplinary services ranging from community based support services to emergency and/or tertiary services;

5) That the Agencies party to the Family Safety Framework should ensure that their staff have appropriate knowledge and training to identify and assess cases to determine risk under the Family Safety Framework. Where ‘high’ risk of future violence is determined each Agency should have clear referral and procedural pathways, through nominated representatives, to Family Safety Meetings as well as clear feedback mechanisms from those meetings to inform case and safety planning for interventions specific to the agency.


8.3. Recommendations - Deaths In Custody

Where a recommendation is made in relation to a death in custody, the Minister responsible for the agency or instrumentality of the Crown to which a recommendation is directed must, within eight sittings days of the expiration of six months after receiving a copy of the findings and recommendations, cause a report to be laid before each House of Parliament giving details of any action taken or proposed to be taken in consequence of the recommendations, and forward a copy of the report to the State Coroner. During the year under report the following recommendations were made in cases of deaths in custody:

Brown, Lance Clive (Coroner Schapel)

I recommend that the Minister for Health consider introducing legislation before the South Australian Parliament similar to that encompassed within the Northern Territory Volatile Substance Abuse Prevention Act 2005, that has general application within the entire South Australian jurisdiction and which is specifically targeted towards volatile substance abuse.

Hayward, Robyn Eileen and Durance, Edwin Raymond (Coroner Schapel)

From the preliminary Finding - It seems to me that in the light of the incidents to which this Inquest relates, it would be appropriate to make a recommendation that the Framework be implemented within the Murray Mallee SAPOL LSA at the first available opportunity, consistent with affected and involved entities being able to bring the necessary resources to bear on its implementation. I recommend accordingly.

I make the following recommendations which for the purpose of section 25(5) of the Coroners Act 2003 are made in the matters of both Hayward and Durance. I direct the recommendations to the attention of the Attorney-General, the Minister for Communities and Social Inclusion, the Minister for the Status of Women and the Commissioner of Police:

1) That the Bail Act 1985 be amended to preclude the granting of bail in cases of alleged domestic violence, such as assault on a family member, by any bail authority other than a Court;

2) That all cases of alleged domestic violence, such as an assault on a family member, be in any event brought before a Magistrates Court within 48 hours of the arrest of the alleged perpetrator;

3) That the Bail Act 1985 be amended so as to require in any bail agreement in cases of alleged domestic violence, such as assault on a family member, a condition in the same terms as the ‘firearms term’ as set out in the Intervention Orders (Prevention of Abuse) Act 2009;

4) That the Commissioner of Police cause applications for intervention orders pursuant to the Intervention Orders (Prevention of Abuse) Act 2009 to be routinely made in all cases where a person has been arrested for or charged with an offence involving domestic violence;

5) That the Commissioner of Police cause to be established a body of intelligence in respect of serial or repeat domestic violence perpetrators that would include information in relation to individual perpetrators that is readily accessible to officers,


(a) as to perpetrators’ propensity to possess and use firearms, (b) their propensity to breach conditions of bail, (c) their history of drug and alcohol abuse, (d) their criminal history including details as to past offences involving violence and ancillary reports regarding their past behaviour, (e) any other relevant information;

6) That the Commissioner of Police cause to be reinforced among members the need to include as part of any investigation of alleged domestic violence the taking of statements from all relevant witnesses at the earliest opportunity;

7) That the Commissioner of Police cause to be reinforced among members the need to consider on an ongoing basis the possibility that the alleged perpetrator of domestic violence may have access to a firearm and the need to make proper and due enquiry as to the alleged perpetrator’s access to a firearm;

8) That the Commissioner of Police cause to be reinforced among members the need to enquire of the alleged victim of domestic violence on an ongoing basis as to whether or not the alleged perpetrator is complying with conditions of bail or with an intervention order;

9) That the Commissioner of Police consider whether in cases of domestic violence that involve an assessment of high risk of repeated violence to the victim, surveillance should be conducted in relation to the activities of the alleged perpetrator with a view to establishing whether or not the alleged perpetrator is complying with conditions of bail or with an intervention order;

10) That domestic violence services and agencies throughout South Australia be encouraged to routinely divulge to SAPOL any information in the possession of the service or agency to the effect that the alleged perpetrator of domestic violence may have possession of or access to a firearm;

11) That domestic violence services and agencies throughout South Australia be encouraged to maintain individual records in relation to serial or repeat domestic violence perpetrators;

12) That domestic violence services and agencies throughout South Australia be encouraged to inform SAPOL of suspicions of breach of bail agreements and intervention orders by alleged perpetrators of domestic violence;

13) That domestic violence services and agencies throughout South Australia be encouraged to make repeated enquiry of alleged domestic violence victims as to whether or not the alleged perpetrator is complying with conditions of bail or with an intervention order.

Rex, Michael David (Coroner Schapel)


1) That the principal administrative officer or equivalent of the Margaret Tobin Centre give further consideration to the implementation of SAPOL recommendations 1 to 4 as set out in paragraph 7.2 herein;

2) That the principal administrative officer or equivalent of the Margaret Tobin Centre take the necessary steps to ensure that upon the death of a patient within the Centre,


all CCTV footage is retained and not overwritten until permission to do so has been obtained form the State Coroner or SAPOL.

Rigney, Vincent Norman (Coroner Johns)


1) I recommend that the Department for Correctional Services institute a 24 hour nursing service at Port Augusta Prison and investigate the institution of such a service at all other prisons within the State.

2) I recommend that the Department for Correctional Services provide public access defibrillators or automated external defibrillators to any prison in the State that does not have 24 hour nursing facilities.

3) I recommend that the Department for Correctional Services and the South Australian Prison Health Service investigate the provision of enhanced cardiac screening for prisoners as suggested by Dr Heddle.

Xu, Yan Yi (Coroner Schapel)

At the conclusion of the evidence and final addresses in this Inquest I delivered a brief extempore finding and recommendation that I now repeat.

'Ms Xu had hung herself from a shower tap, utilising a towel or towels as a ligature. The tap constitutes an effective hanging point.…I am told in the affidavit of Dr Elias Rafalowicz that the necessary requests, quotations and approvals for a number of specific works, including replacement of all shower taps and heads, is to be completed by 12 November 2010.

I recommend that the alteration which includes, as I understand it, the replacement of shower taps similar to those that Ms Xu used as a ligature point, be expedited. I direct that recommendation to the Executive Director of the Adelaide Health Service, Mental Health Service, Central and Northern and would add that I would also recommend that the alterations and modifications and replacements of other identified hanging points, as mentioned in the material attached within and to the affidavit of Dr Rafalowicz, be implemented as soon as possible.'

I make the following additional recommendations directed to the Minister for Mental Health:

1) That ACIS workers refrain from making an assessment of risk of self-harm that differs from that of the referring medical practitioner or other health care professional without consulting that medical practitioner or other health care professional. In this regard I refer to a similar recommendation made by this Court in the matter of the death of Patricia Susanne Jericho on 6 November 20025;

2) That ACIS workers be required in making any assessment of risk of self-harm that they endeavour to access all information about the longitudinal mental health history of the patient that is in the possession of ACIS or other Department of Health entity;

5 Inquest 19/2002, Recommendation 5


3) That ACIS workers be required in making any assessment of risk of self-harm that they endeavour to seek as much information as they are able from relatives and family members of the person being assessed;

4) That systems be developed within the Department of Health that would enable staff of the SAMHS to access all information regarding the mental health history of a patient however stored, whether electronically or otherwise. In this regard I refer to the comment made by Doctor Raeside in his report that the case:

'Does again highlight the desirability of one treating area being able to readily access past details of admissions, rather than simply obtaining discharge summaries. I understand that there have been repeated coronial recommendations in this regard and progress has been slow';

5) That clinicians employed at psychiatric facilities of public hospitals be reminded of the need to obtain ‘collateral information’ concerning recently admitted patients and that the information should be obtained as soon as possible following admission, even if it means that the information has to be obtained on a weekend or on a public holiday.

8.4. Response to Recommendations - Deaths In Custody

During the year the subject of this report, the following reports detailing any actions taken or proposed to be taken in consequence of recommendations made in the case of a death in custody, were received by the State Coroner:

Brown, Lance Clive (Coroner Schapel)

Recommendation 1 - That the Minister for Health consider introducing legislation before the South Australian Parliament similar to that encompassed within the Northern Territory Volatile Substance Abuse Prevention Act 2005, that has general application within the entire South Australian jurisdiction and which is specifically targeted towards volatile substance abuse.

SA Health has:Reviewed the Northern Territory Volatile Substance Abuse Prevention Act 2005 and compared it to existing South Australian legislation for the management and prevention of volatile substance abuse.Reviewed the evidence for compulsory treatment.Consulted with relevant South Australian government agencies and the Aboriginal Health Council of South Australia Incorporated.

SA Health will:

Review the Public Intoxication Act 1984 and declare sobering up centres under the Act and the expansion of the definition of ‘drug’ to include all volatile substances.Provide training for South Australia Police and health professionals on the acute and chronic effects of volatile substance misuse on the individual and the recommended management and training in the use of the Mental Health Act 2009 by South Australia Police in cases of acute intoxication.


Investigate opportunities for voluntary diversion for assessment and/or treatment by South Australia Police for a person known or suspected to be misusing volatile substances.Work with the Guardianship Board of South Australia and Public Advocate on a short term project to identify opportunities to apply the Guardianship and Administration Act 1993 to individuals with mental incapacity and who are at risk due to severe substance abuse.Build the capacity of the South Australia Police and health professionals to utilise existing powers in managing an individual with mental incapacity and severe substance dependence.Work with relevant agencies to implement and monitor effective prevention and voluntary treatment approaches over a two year period, prior to determining whether additional legislation for compulsory treatment is required.

Hayward, Robyn Eileen and Durance, Edwin Raymond (Coroner Schapel)

From the preliminary Finding - It seems to me that in the light of the incidents to which this Inquest relates, it would be appropriate to make a recommendation that the Framework be implemented within the Murray Mallee SAPOL LSA at the first available opportunity, consistent with affected and involved entities being able to bring the necessary resources to bear on its implementation. I recommend accordingly.

The Murray Mallee LSA, being the specific area of concern in the Coroner’s preliminary finding, has been divided into its two main population areas of Berri and Murray Bridge for the purpose of conducting Family Safety meetings. Training for the meeting process was conducted at Berri on 18 October 2011 by Office for Women (OFW) for all involved stakeholders. Meetings then commenced at Berri in November 2011 and have since been held at regular fortnightly intervals. Similar training was conducted at Murray Bridge on 9 December 2011 by OFW with the first meeting held at Murray Bridge on 31 January 2012.

Family Safety Framework meetings are operating in all South Australia Police metropolitan Local Service Areas (LSAs) and four country LSAs, being Far North (Port Augusta), Yorke Mid North (Port Pirie), Limestone Coast (Mount Gambier) and Murray Mallee (Berri and Murray Bridge).

Lee, Troy Thomas and Matthews, Scott Leslie (Coroner Schapel)

Recommendation - Whether or not DCS officers should actually be professionally trained to recognise and manage ‘at risk’ home detainees is a matter that is not free from difficulty. One matter that would require consideration in this regard is whether it would be appropriate for such officers to assume such a high duty of care. In this case there is insufficient evidence to suggest that such formal training would, or might, have altered the outcome in either of these two cases. However, the need for such training is a matter that the Minister for Correctional Services and the Chief Executive of the Department for Correctional Services should consider and I recommend that they do so. The above recommendation is particularly relevant to issues that were already being

explored by the Department for Correctional Services at the time the findings were handed down.


A Crisis Intervention and Support Service project commenced in December 2010. The intention of the project being to develop a consistent approach to responding to offenders who have been identified as being at risk of self harm and/or suicide.

This large project has been broken into two phases; the initial phase, which was focused on prisoners within the custodial setting; and the second phase, focused on the management of offenders subject to community based supervision.

Although processes have already been established to raise and manage concerns about a prisoner identified as being at risk of self harm or suicide, this project plans to extend these processes out into the community so that community based resources can be arranged to best support the offender upon their release.

The Community Corrections component aims at: developing processes to support the timely and efficient communication of .

offender management details across directorates when the offender is released into the community, returned to custody, or remains in the community under supervision;

developing processes for escalating the management of offenders experiencing a crisis; and

developing and providing training to Community Corrections staff in exercising the outcomes of this project.

Established processes from the initial phase will enable relevant information to be sent to the appropriate location in a timely manner. In cases where the offender is returned to prison, information from the community will be easily accessible by the relevant location.

The development of a staff training package is currently being finalised, with the delivery of this training package scheduled to commence in mid September 2011. The training will include the use of a Risk Escalation Matrix that has been developed to guide staff in determining priority actions when presented with an offender at risk of self-harm or suicide.

32 of 43 Home Detention officers have now been provided the Department's training in Suicide Awareness. The remaining 11 staff will attend future training sessions when it is available to ensure all Home Detention officers have this level of training.

Once staff training is completed, the outcomes will be presented to the Department's Executive.

In conclusion, although the Department is committed to progressing this initiative in order to maximise the support that can be offered to offenders both in prison and in the community, the Deputy Coroner has acknowledged that the matter of professionally training staff to recognise and manage 'at risk' home detainees is a matter that is not free from difficulty, and that consideration must be given to whether it is appropriate for officers to assume such a high duty of care. He further quite rightly notes that there is little evidence to suggest that such training would, or might have altered the outcome in either of these two cases.

Rex, Michael David (Coroner Schapel)


Recommendation 1 - That the principal administrative officer or equivalent of the Margaret Tobin Centre give further consideration to the implementation of SAPOL recommendations 1 to 4 as set out in paragraph 7.2 herein;

SA Health has considered the implications of implementing the four South Australia Police recommendations and provides the following comments.

1.1 Mental Health Services are required, and aim to, provide the least restrictive environment for the therapeutic benefit of all consumers. The rear garden fencing at Ward 5H of the Margaret Tobin Centre, Flinders Medical Centre maintains privacy and promotes a boundary to the property. It is not intended to be a secure area. To reconstruct the fence to ensure that illicit drugs are not passed or thrown over the fence would promote a prison-like environment that is not conducive to a recovery framework.

1.2 The requirement to sign in visitors in mental health units is inconsistent with SA Health hospital procedures and stigmatises mental health consumers and their visitors. Documentation of visitor interactions in a consumer medical record is completed where it is considered to be of clinical relevance. The Margaret Tobin Centre is currently developing a local visitor’s procedure, which will be very similar to the former Central Northern Adelaide Health Service’s procedure. The former Central Northern Adelaide Health Service’s procedure included encouragement of visitation and provided that consumers should have the opportunity to communicate with others in privacy unless contraindicated on safety or clinical grounds. The location used for mental health care was required to provide an opportunity for sight and sound privacy. In addition, visitors are allowed in designated areas of inpatient units only and should be able to be observed by staff at all times. The visitors may be requested to surrender potentially dangerous items prior to the visit occurring. The visit will be postponed should the visitor refuse.

1.3 A Margaret Tobin Centre nursing observation chart was trialled and approved by the Medical Records Committee on 1 December 2009. It was finalised and approved in September 2011 outlining minimum nursing visual observation requirements, including night time observations. Since the introduction of the nursing observation chart, reviews have occurred in the context of broader medical record audits carried out on a regular basis. Medication management training is an annual mandatory requirement, which all nursing staff are required to undertake. In relation to refresher training, 90 per cent of Margaret Tobin Centre nursing staff completed their training in 2010 through the Centre for Nurse and Midwife led Research Online Training Service. Medication audits were conducted as per schedule on 1 July 2010, 5 November 2010 and 30 September 2011.

1.4 A Local Health Network Clinical Procedure, Reporting deaths to the Coroner, has been developed and implemented.

Recommendation 2 - That the principal administrative officer or equivalent of the Margaret Tobin Centre take the necessary steps to ensure that upon the death of a patient within the Centre, all CCTV footage is retained and not overwritten until permission to do so has been obtained from the State Coroner or SAPOL.


In consultation with the Agency Security Advisor, there will be an amendment to local procedures at the Margaret Tobin Centre to ensure that any ‘death in custody’ will be notified to the SA Health Agency Security Advisor, who will ensure CCTV footage is retained and not overwritten until permission to do so is granted.


Rigney, Vincent Norman (Coroner Johns)

Recommendation 1 - I recommend that the Department for Correctional Services institute a 24 hour nursing service at Port Augusta Prison and investigate the institution of such a service at all other prisons within the State. Actions taken by SA Health

While this recommendation was primarily directed to the Department for Correctional Services SA Health has been involved in discussions, as it provides nursing services at Port Augusta Prison Health Centre.A review of the number of prisoners requiring transfer to hospital from Port Augusta Prison for the period September 2010 to September 2011 was conducted. It was determined that during that timeframe six ambulance transfers occurred outside health centre hours with all prisoners returned to Port Augusta Prison the following day, with no medical issues. This information was considered during discussions between Port Augusta Hospital and South Australian Prison Health Service. Both services have agreed that due to the low number of transfers required and close proximity of the hospital to the prison, a 24 hour service at Port Augusta Prison is not required. The current practice of emergency medical care being provided at Port Augusta Hospital will continue when a prisoner requires medical care, which cannot be effectively managed by prison health services.The establishment of 24 hour nursing services in other prisons throughout South Australia was also investigated. Currently, the Adelaide Remand Centre and Yatala Labour Prison have 24 hour nursing services, with transfer to a hospital setting if further care is required. At this stage, it was identified that current demand at other sites does not support the introduction of a 24 hour nursing service.

Response from Department for Correctional Services

Health services for prisoners are provided by the South Australian Prison Health Service (SAPHS). In regards to the above recommendation, the Department has consulted with the SAPHS in relation to the introduction of a 24 hour nursing service at Port Augusta Prison. The SAPHS has advised that having a 24 hour nursing service at Port Augusta Prison and other prison locations is not a viable option at this point in time. Currently, prisoners accommodated at the Port Augusta Prison who require emergency medical care are escorted to the Port Augusta Hospital, for assessment and treatment as required. As such, this will continue to be the course of action taken in instances where a prisoner requires medical care beyond that which can be effectively managed by prison health staff. The same reasons are relevant for other prisons with prisoners requiring emergency medical care escorted to an appropriate hospital. Yatala Labour Prison and the Adelaide Remand Centre have medical health facilities and provide 24 hour nursing services. Male or female prisoners who require health treatment or medical observation, are transferred to Yatala Labour Prison's 24 hour health centre as required.


All other prisons have health centres with qualified SAPHS nursing staff on duty during the day. Mount Gambier Prison is operated by G4S Custodial Services Pty Ltd and health services are provided by G4S under the contract.

Recommendation 2 - I recommend that the Department for Correctional Services provide public access defibrillators or automated external defibrillators to any prison in the State that does not have 24 hour nursing facilities. Response from Department for Correctional Services

All health centres in the state's prisons are equipped with Automated External Defibrillators (AED) for emergency use by medical staff. The AED is a small, portable, easy to operate medical device that is designed to deliver an electric shock to a person who is having a sudden cardiac arrest. AEDs provide step by step voice and visual commands to the operator and are designed in such a way that they will analyse and only deliver a shock to patients who require such treatment. Based on the Coroner's recommendation, it is the intention of the Department to place a minimum of one AED in each prison readily available 24 hours a day for departmental staff. Larger prisons will have more than one defibrillator available. These will be securely stored in appropriate locations in order to provide a rapid response to critical incidents AED training is already being provided to all custodial staff through their Senior First Aid Certificate training, and the AED systems can be safely and successfully operated by a person with little or no training in emergency situations. As there are a number of various AEDs available for purchase, the Department is currently in the process of identifying units suitable for the Department's use. As the planned rollout progresses, relevant staff will be provided with information about these units and of their specific locations within each prison, to ensure these devices can be readily and promptly accessed in the event of an emergency.

Recommendation 3 - I recommend that the Department for Correctional Services and the South Australian Prison Health Service investigate the provision of enhanced cardiac screening for prisoners as suggested by Dr Heddle.

Actions taken by SA Health

South Australian Prison Health Service has conducted a review and analysis of the options for the provision of enhanced cardiac screening for prisoners, as suggested by Dr Heddle. This was conducted by Dr Peter Frost, Clinical Director of South Australian Prison Health Service and focused on current recommended approaches to cardiovascular disease in Aboriginal and Torres Strait Islander prisoners.A clinical report identifying strategies for the screening and management of cardiovascular disease in all prisoners at risk has been submitted to the South Australian Prison Health Service Executive for consideration. Implementation strategies have been included. The report provides advice for systematic cardiac screening practices throughout South Australian Prison Health Service. South Australian Prison Health Services admission documents (the assessment tool) have been amended to include preliminary assessment for high risk areas, including cardiovascular disease. The assessment tool will be piloted in March 2012 at the Adelaide Remand Centre, with implementation in all sites to follow. Information obtained from these assessments will


be used to identify prisoners that require referral for additional cardiovascular screening.

Response from Department for Correctional Services

As this recommendation is for a health service provision to prisoners, this recommendation will be responded to in full by Health. The Department for Correctional Services will work with SAPHS to facilitate and assist with the implementation of a process for screening, which I understand is to be developed and implemented in 2012.

Xu, Yan Yi (Coroner Schapel)

Recommendation 1 (preliminary finding) - I recommend that the alteration which includes, as I understand it, the replacement of shower taps similar to those that Ms Xu used as a ligature point, be expedited.

All remedial building work on ligature points identified by the inquest has been completed.

Recommendation 2 (preliminary finding) - I would also recommend that the alterations and modifications and replacements of other identified hanging points be implemented as soon as possible.

A ligature audit of Cramond Clinic was completed on 22 September 2010 and remedial work was identified. All remedial work to address ligature points has been completed.

Recommendation 1 - That ACIS workers refrain from making an assessment of risk of self-harm that differs from that of the referring medical practitioner or other health care professional without consulting that medical practitioner or other health care professional.

The main route for referral to an Assessment and Crisis Intervention Service team for a mental health assessment is through the Mental Health Triage service. This service comprises senior staff skilled and experienced in mental health triage, which includes liaison with the referrer. Mental Health Triage make a referral as appropriate to Assessment and Crisis Intervention Service teams and the Mental Health Triage assessment of risk with defined response times for each level, are not able to be changed by the Assessment and Crisis Intervention Service until face-to-face assessment with the consumer has occurred.

Where a referral to the Assessment and Crisis Intervention Service is received direct from another health care professional, and a comprehensive assessment by Assessment and Crisis Intervention Service results in a differing risk rating, it is standard practice that liaison with the referrer occurs when this is possible.

In assessment of risk of harm to self or others, staff are required to take into account and assess all of the information provided to them. This includes longitudinal risk, as assessed by a general practitioner or other referrer. If staff are unable to ascertain the reason for a high risk assessment level they should contact the referrer if possible.

Recommendation 2 - That ACIS workers be required in making any assessment of risk of self-harm that they endeavour to access all information about the longitudinal mental health history of the patient that is in the possession of ACIS or other Department of Health entity.


The longitudinal mental health history of the consumer is available through the Community Based Information System, the system used for reviewing collateral information regarding recently admitted consumers. Staff are encouraged in the training to access the Community Based Information System for longitudinal mental health history. Western Assessment and Crisis Intervention Service staff received refresher training in the use of the Community Based Information System in 2011.

Recommendation 3 - That ACIS workers be required in making any assessment of risk of self-harm that they endeavour to seek as much information as they are able from relatives and family members of the person being assessed.

All staff are required to seek information from relatives/family members when completing a mental health (including risk) assessment. Staff training in relation to the new Mental Health Act 2009 occurred monthly in 2011, which included information about the collection and release of confidential information previously prohibited by the previous Mental Health Act 1993, in particular where there is a high level of assessed risk of harm to self or others.

Recommendation 4 - That systems be developed within the Department of Health that would enable staff of the SAMHS to access all information regarding the mental health history of a patient however stored, whether electronically or otherwise.

This recommendation will be addressed through SA Health’s Enterprise Patient Administration System. One of the benefits of the Enterprise Patient Administration System will be sharing information electronically across all of health to improve the coordination of health services through increased accessibility, accuracy and timelines of patient information. The contractor has been appointed and the design phase will occur in 2012. It is anticipated that the Enterprise Patient Administration System will be operational in 2013. In the meantime, staff utilise the Community Based Information System to record current updates.

Recommendation 5 - That clinicians employed at psychiatric facilities of public hospitals be reminded of the need to obtain ‘collateral information’ concerning recently admitted patients and that the information should be obtained as soon as possible following admission, even if it means that the information has to be obtained on a weekend or on a public holiday.

All mental health staff in public hospitals have access to the Community Based Information System for reviewing collateral information regarding recently admitted consumers. Mental health staff at the Royal Adelaide Hospital have received Community Based Information System training and have had a refresher training session in 2011.

Ryan, Rhys Allan Gerard and Henschke, Jake Spencer (Coroner Schapel) Wanganeen, Derrick Terence Lee (Coroner Schapel)

Recommendation 1 - That the Commissioner of Police define and exemplify the expression ‘minor traffic matters’ as utilised within the current General Order relating to police high risk driving, and provide police with some guidance within the document, as well as general training, relating to the need to avoid conducting high risk driving including pursuits in the investigation of offences of driving an unregistered and uninsured motor vehicle;


SAPOL is currently revising its General Order, Operational Safety –High Risk Driving. This will include a review of the risk assessment guidelines, with an examination of factors that members will need to take into account (such as the seriousness of any offence) when engaging in high pursuit driving.

Recommendation 2 - That the Commissioner of Police amend the said General Order by including specific reference to the need to avoid conducting high risk driving including pursuits on unfounded supposition that the pursued vehicle might be stolen or that the occupants of the vehicle might be engaged in illegal activity; SAPOL is currently revising its General Order, Operational Safety –High Risk Driving.

This will include a review of guidelines to assist members in their decision making processes when determining the need to engage in high pursuit driving.

Recommendation 3 - That the Commissioner of Police amend the said General Order by including specific reference to the need, in any risk assessment when conducting a pursuit, for the pursing police officer and any incident controller to consider the real possibility that the driver of the pursued vehicle may have an impaired driving ability by reason of that person’s consumption of alcohol or drugs and that a pursuit should not be conducted where there is a suspicion that the driver of the pursued vehicle is

SAPOL is currently revising its General Order, Operational Safety –High Risk Driving. The matters raised by the Deputy Coroner in this recommendation have been included for consideration in the overall review.

Recommendation 4 - That the Minister for Transport initiate such public awareness campaigns designed to draw the attention of the general public to the folly connected with, the extreme dangers presented by, the futility of and the likely tragic outcomes associated with intoxicated drivers of motor vehicles endeavouring to evade police.

The Motor Accident Commission (MAC) funds and manages the State Government's road safety communications campaigns. These campaigns aim to raise awareness of road safety issues and influence driver's decisions when they are behind the wheel. Campaigns address the key road safety issues of speeding, drink and drug driving, seatbelts, fatigue, motorcycling and pedestrian safety.

Campaigns are based on extensive market research and crash/infringement statistics to ensure messages are communicated to appropriate target markets for each issue. MAC is cognisant that there is a small number of people in the community who are recidivist, high-risk driving offenders. MAC's research shows that advertising may have limited influence on this small group of people's behaviour as they have little or no regard for their own safety or that of the community.

MAC has advised that it will work with SA Police to communicate the dire road safety consequences that can result from evading police in media interviews when possible and appropriate.

SAPOL has advised that the last fatal pursuit in South Australia was on 6 May 2009, and has stated that it "considers that a specific 'public awareness campaign' as recommended by the Deputy Coroner may be of limited value and perhaps not the best use of available resources."


The Department for Transport Energy and Infrastructure will also highlight the risks of high speed pursuits by including information on its road safety website www.dtei.sa.gov.au/roadsafety.


http://www.dtei.sa.gov.au/roadsafety

9. Manager’s Report

9.1. Registry Report

The Manager of the Coroners Court has responsibility to oversee the financial and administrative functions of the office. The Manager also has a number of responsibilities delegated from the Coroner in order to manage a range of quasi judicial functions as designated by the legislation.

There are 14.7 full-time equivalent (FTE) administrative staff (this number includes locum social workers) plus 2 FTE Counsels Assisting attached to the Coroners Court.

The role of coronial staff is to support the State Coroner and the Deputy State Coroner to undertake their inquiries with accurate and timely information. The office also provides a support service for families and provides access to information to certain approved parties, such as lawyers, insurance companies and medical practitioners.

The Court has continued to work towards improving procedures and systems for managing the work volume and complexity within limited resources. Staff have contributed in consultations to provide feedback to the team developing the new case management system. The Coroners Office Case Management System is a significant initiative in this jurisdiction and a number of staff have contributed many hours of their time to ensuring that the system will provide business enhancement, data collection for the NCIS and management reporting capabilities.

Our work has also been enhanced by using dual computer screens to enable staff to work simultaneously between two systems, and by all staff participating in a yearly open file audit process. All cases are assigned to a staff member who case manages the file to monitor that all investigation reports are received and progressed in a timely manner.

All staff participate in two formal Performance Development meetings with their supervisor each year. This meeting focuses on goals and achievements and determines the best staff development plan for each person.

Occupational Health, Safety and Welfare has progressed well this year and we have demonstrated compliance with Courts Administration Authority policies and procedures through the dedicated attention of our OHS&W representative and the periodic audits that occur through Corporate Services.

A majority of the goals set out in the 2011-2013 Business Plan were achieved and the plan will be reviewed in the next financial year.

The Court is approached by many research agencies and community groups throughout the year seeking information about death statistics. In most cases


these entities are referred to the National Coronial Information System as the Coroners Court does not have the time or the expertise to respond to the volume of requests. However, there are a small number of bodies that the State Coroner allows access to information, such as death review committees. In addition to this, as mentioned on page 9, the joint initiative between the Coroners Court and the Office for Women on Family Safety and Domestic Violence has enabled the Senior Research Officer access to coronial cases. We are also participating in two separate research projects, using one of our locum social workers, which research sudden cardiac deaths and the deaths during the 2009 South Australian heatwave. It is considered that both of these projects have a potentially beneficial health and safety impact on the community. The salary costs of these three research projects are met by the agencies conducting the research.

Once again I am proud to acknowledge the wonderful work of the staff of the Coroners Court. They are met with a relentless stream of work on a daily basis and are always remarkably composed, hard working and cheerful. During the year under review the Courts Administration Authority released the report of a staff survey. Overall the results for Coroners Court were very positive and demonstrated high levels of staff work satisfaction and commitment. Staff are proud of their work and the assistance they provide to the Coroner and to families, however staff are concerned that there is little career progression in the Coroners Court and commented that they were dissatisfied with general resources, particularly in relation to staffing numbers.

During the year under review the CAA launched its first Staff Awards program. The Coroners Court is proud to announce that one of our Administrative Services Officers, Laura Millard, was nominated and won the award for ‘Service Improvement or Innovation’. Ms Millard had consistently improved systems in administration for the Coroners Court above and beyond her normal daily duties. Most importantly she was integral in developing the scoping project for the Coroners Office Case Management System.

The Manager has continued to be available to outside agencies such as hospitals, health related students and general interest groups for speaking engagements. These sessions enable the Manager to educate the community and health care professionals about the Coroners Act and the coronial process. During the year under review the Manager attended 9 speaking engagements and addressed approximately 220 people.

9.2. Counselling Service

The South Australian Coroners Court employs two senior social workers. They provided first contact calls to families as well as providing coronial social work services for the State Coroner and the Deputy State Coroner.


9.3. Organ Retention

The Coroner is responsible for the investigation of the cause and circumstances of reportable deaths in South Australia. Organ retention may feature when the cause of death is required to be determined via a post mortem examination. In certain deaths however, a post mortem does not always reveal the cause of a person’s death. In these situations further investigations and tests are carried out. These investigations and tests can involve the retention of organs and tissue. The Court’s social workers have the role to inform and seek the views from the deceased’s senior next of kin with respect to organ retentions.

For the 2011-2012 financial year there were 158 deaths that involved the retention of one or more organs or tissue for specialist testing. This accounted for about 7.5% of all reported deaths. This number is up by 1.5% on the previous year.

In total there were 220 human organs and tissue retained during the 2011-2012 financial year. Figure 1 shows that 144 brains were retained for neuropathology testing. Once specialist tests on the organs and tissue are completed, the deceased’s senior next of kin are able to direct the Court on how to dispose of their relative’s organs or tissue.

Figure 2 is a breakdown of the method of disposal of organs and tissue. At the expressed direction of the senior next of kin, 59% (n=85) of organs and tissue were donated to research. Approximately 19% (n=27) choose to have the retained organ or tissue returned to their funeral director. The funeral director would either have the organ or tissue cremated, returned to the deceased’s body or to the grave. About 22% (n=31) of organs and tissue were returned to the deceased’s body prior to the body being released to a funeral director. Only 10% (n=15) directed the FSSA to respectfully dispose of the retained organs and tissue via cremation.


Retained organs and tissue must be kept in a preserving chemical before specialist tests can begin. Human brains, for exampe, are kept in formalin for approximately 2 to 3 weeks before a neuropathologist can undertake any micro or macro neuropathology examinations. This whole process may affect timeframes related to when families can bury or cremate their relative. Figure 3 and Figure 4 show the time taken for the organ retention process to be completed where the organs and tissue are returned to the deceased’s body or funeral director respectively. The mean time taken for the organs and tissue to be returned to the body before release was 19 days with a standard deviation of 7 days. The mean time taken for the organs and tissue to be returned to the deceased’s funeral director was 20 days with a standard deviation of 8 days.


9.4. Disaster Victim Identification

The Manager of the Coroners Court is a member of the State Disaster Victim Identification Committee. The Committee is responsible for the coordination of the identification of the victims of any single incident where the number of fatalities is more than three.

During May 2012 the Deputy State Coroner and the Manager of the Coroners Court attended the DVI exercise, Operation Balloon. This was a temporary mortuary facility set up as a DVI response unit at the Adelaide Airport. The exercise had the participation of SAPOL, Forensic Science SA and Forensic Odontologists as well as ancillary support services. Lessons had been learned from the Christchurch, New Zealand, earthquake disaster victim recovery and identification processes and were applied to this scenario with good effect. Each year that this exercise is staged and ‘real time’ situations are rehearsed, the responses, facilities and amenities are improved.

It is hoped that at next year’s exercise a staff member from the Coroners Court can be on site to simulate the administrative work of the Coroners Court at this stage of a DVI exercise.

In 2012 a tragic accident occurred on Lake Eyre when a helicopter crashed and caused the loss of three lives. This incident was not strictly a DVI event, however the nature of the accident meant that certain principles of DVI were employed to manage the site, retrieve the bodies and subsequently identify the bodies. This event was complex due to the remote location of the accident site and the severity of the impact of the helicopter. A number of specialists attended the scene to secure and grid the site, examine the deceased and the helicopter and begin the forensic examination and recording of the site.

With regards to this event the DVI principles that were employed included:

Daily updates to the State Coroner; Securing and coordination of the site (Forensic pathologist in attendance); Retrieval of bodies and subsequent body identification techniques and

reconciliation; DVI post mortem functions; Full FSSA identification reports and SAPOL reports provided to the State

Coroner; Coronial Social Workers providing regular and detailed updates,

information and support to the senior next of kin; Property management.


10. Staff Roles and Organisational Chart

The Business Unit is structured according to the following organisational chart:

Management Team consists of the Manager, Deputy Manager, Operations Coordinator and the Social Workers. This group provides strategic direction to the administration team and provides leadership in the areas of Business Planning, Business Continuity Planning, OHSW, human resource management and the general day to day functions of the registry.

Coronial Services Officers and Administration Officers in the Registry receive reports of death from SAPOL, hospitals and aged care facilities. The role also involves coordinating initial investigations, reporting matters to the State Coroner, referring matters for investigation and authorising and arranging the conveyance of deceased persons within the State. This section of the business unit also attends to correspondence, manages reception duties, and provides a ‘quality assurance’ service to the data entered into the national coronial database.

Social Workers provide initial grief and crisis counselling during the time immediately following the death, they provide specific information about the coronial process and they assist families in preparing to attend an Inquest.


The Social Workers also provide referrals to those who are bereaved to longer term services, both counselling and support groups. The Social Workers play an important role in talking to families about the post mortem process, particularly where tissue/organs have retained for further examination.

Inquest Support Officers provide assistance to Counsel Assisting in preparing Inquests and issuing Court documents, notifying and liaising with stakeholders and next-of-kin and ensuring appropriate information is recorded and provided to relevant parties. They provide a confidential administrative service to Senior Counsel Assisting/Counsel Assisting the State Coroner and Deputy State Coroner by typing from manuscript or digital Dictaphone, conducting file management on a large number of files and exhibits and responding to various correspondence. They also provide information pertaining to the conduct of coronial Inquests by liaising with administration, counsel and the public and other interested parties regarding documents and other information requested and provision of appropriate responses and action.

Personal Assistant to the State Coroner provides a confidential and efficient typing, clerical, secretarial and administrative service to the State Coroner and provides general support to Inquest Support Officers as required.

The Counsel Assisting the State Coroner and Deputy State Coroner works to provide legal services to the State Coroner and Deputy State Coroner, preparing matters for Inquest and ensuring that matters are listed for Inquest in an orderly and efficient manner to make the best use of the Court’s resources. This position also prepares legal matters pertaining to complex investigations and formulates advice to the State Coroner that will assist in determining whether an Inquest is necessary or desirable.

There are two Counsels Assisting assigned to the State Coroner and Deputy State Coroner and they are assisted in the preparation of Inquests by two Inquest Support Officers.

The major responsibilities of Counsels Assisting are:

Liaising with the State Coroner, Deputy State Coroner, Senior Counsel Assisting and other personnel in relation to all coronial functions;

Preparation of matters for Inquest which are of a complex and sensitive nature;

Conducting cases considered complex and sensitive in nature as Counsel Assisting the State Coroner and Deputy State Coroner at Inquests;

Providing verbal and written legal advice to the State Coroner and Deputy State Coroner;

Liaising with investigators from SAPOL, Workplace Services and other agencies, witnesses and members of the public as required;


Ensuring that in dealing with all issues pertaining to social, ethnic and cultural sensitivities, the dignity and rights of those involved in coronial Inquests are preserved.

The role of Counsel Assisting demonstrates the values of the Courts Administration Authority by practising law with integrity and professionalism and by respecting the Coroners, the Court and their legal colleagues. Counsels Assisting provide a service to the South Australian community by inquiry into circumstances of death in order to advise the Coroners so that they may make recommendations that will prevent the likelihood of a similar occurrence in the future.

Senior Researcher (Domestic Violence)The Senior Research Officer (Domestic Violence) contributes to the provision of a comprehensive evidence based information service with the Coroners Office. The Senior Research Officer (Domestic Violence) provides leadership and contributes to the conduct and management of complex projects, including research and evaluation activities; the collection and analysis of information; and provide expert advice to clients and key stakeholders.


state coroner’s annual report to the web view23. annual report of the state coroner...

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