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Premier: please hold Royal Commission

Premier: please hold Royal Commission

CLA’s Australia Day letters target important and urgent issues: this year we’re calling on the Premier to launch a Royal Commission into the state of justice in South Australia. 

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The Hon. Jay Weatherill, MP, Premier of SA

Parliament House


Dear Premier

Following the nolle prosequi re Henry Keogh entered by the Director of Public Prosecutions in relation to the Cheney death in 1994, Civil Liberties Australia asks you, as Premier, to hold a Royal Commission/public inquiry into the administration of justice in SA, covering, inter alia:

  • matters surrounding the Keogh and other questionable legal cases*, including the non-charging of possible murderers, resulting from findings and evidence provided by Forensic Science SA and its predecessors;
  • forensic science examinations, findings and evidence given in courts, tribunals, etc by Dr Colin Manock and state forensic science staff from 1968 to the present (including cases interstate where the SA forensic science services undertook examinations for external bodies, such as the NT Government and its agencies, the Australian Federal Police, etc);
  • actions, and inactions re the above, by SA Directors of Public Prosecutions, Solicitors-General of SA, and the Attorneys-General of SA involved in handling the complaints and petitions for mercy made by Henry Keogh and others in the period from 1968 to now;
  • actions, and inactions of the Medical Board of South Australia and the Medical Professional Conduct Tribunal relevant to Dr Manock, other relevant cases, and any other relevant inquiries conducted between 1968 and the present;
  • the past and present ability or otherwise of professional bodies in general in South Australia, such as (but not only) those in forensic science, medicine and law, to adequately monitor, supervise and discipline their professions and their members to protect the public, including their boards’ timely ability to prevent members continuing to operate in the profession if evidence or findings adverse as to propriety, public safety or confidence in the legal, medical, justice and other systems of society arise;
  • any other associated matters.

CLA believes there will be lessons for other jurisdictions, and suggests the SA Government invites other states and territories to send observers to the Royal Commission/Inquiry.

The conduct of Dr Manock was extraordinary over many years. As importantly though, the failure of the justice system – judges, political and legal office holders, the various professional associations – to deal with the situation is the major worry for the quality of justice in South Australia now and into the future, and for justice in Australia more generally.
* including, but not limited to, those of Van Beelen, Bromley, Szach and three babies who died in what may have been non-accidental injury cases.

Yours sincerely,

Dr Kristine Klugman                                                                    Tuesday 26 January 2016



The Government of South Australia needs to restore faith in the state’s justice system by holding a Royal Commission. Cases in the SA Supreme Court have already documented extensive failings of the forensic pathology system in SA. Innocent people have been jailed, some apparently for decades: as importantly, it is possible that some murderers remain at large. The problem is not only faulty forensic work: failures in the legal/criminal justice system, which flowed from the forensic mistakes, have not been addressed or remedied.

Citizens’ confidence has been severely shaken by the outcomes of trials, appeals, tribunal hearings and the like surrounding the professional activities of Dr Colin Manock as head of the state’s forensic pathology facility for more than 30 years. Concerned citizens and leading lawyers have identified significant governance questions surrounding how the legal, medical and other executive bodies in South Australia, including the Parliament, have permitted the state’s system of justice to deteriorate. Nearly two decades after Dr Manock’s retirement, the State has not undertaken a robust investigation of what went wrong across the system, with a view to taking formal remedial action. In fact, as lately as January 2016, the Director of Public Prosecutions appeared ready to rely on evidence from Dr Manock to continue an unjust trial.

1975 – The State of South Australia gave sworn evidence to say that Dr Manock was not properly qualified to certify cause of death;

1981 – The High Court determined that Dr Manock’s evidence was not fit to be taken into account and that he was not an expert;

1995 – The Coroner of SA determined that Dr Manock was incompetent and dishonest;

2004 – Members of the Medical Board of South Australia stated that Dr Manock was incompetent and failed to comply with standards laid down in 1908;

2004 – The report to the Solicitor-General by the SA Government’s most senior pathology expert said that Dr Manock’s evidence in the Keogh case was wrong – there existed no evidence of criminal assault. It was another decade before Keogh was declared innocent.

Appeals before the courts in 2016 will assert that Dr Manock was never qualified as an expert, and therefore his evidence in cases in which he appeared was not admissible under the laws of SA, yet it was accepted for decades. He also is recorded as having given worrying evidence in a number of important cases, notably the alleged battered baby cases in which people may have escaped proper police examination and possible charges.

With the current appeals, the public will want to know how the State of SA and the legal –medical-parliamentary system allowed Dr Manock to help secure over 400 criminal convictions, and preside over the non-charging of other possible criminals, as well as to conduct autopsies in 10,000 cases, when he was not properly qualified.

For the confidence of the citizens of SA, it is important that the systemic failures in state governance methods, which allowed errors and mistakes in association with Dr Manock, be completely and transparently analysed, and learned from. A Royal Commission will ensure the people of South Australia that the State Government is firmly committed to the rule of law.

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