Inquiry into matters arising from the post-mortem and anatomical examination practices of the ...

136 Pages·2001·1.41 MB·English

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ISBN 0 7347 3330 5
©The Government of the State of New South Wales 2001
Further enquiries to:NSW Department of Health,
Locked Mail bag 961,North Sydney,NSW 2059
Telephone:[phone]
Email:[email protected]

INQUIRY INTO MATTERS ARISING FROM THE POST-MORTEM
AND ANATOMICAL EXAMINATION PRACTICES OF
THE INSTITUTE OF FORENSIC MEDICINE
TABLE OF CONTENTS
Page Para
3 Introduction
4-8 Methods 2-12
8 Term of reference 13
8-40 Legislative Framework 14-79
11-19 Coroners Act 1980 19-32
19-21 Births, Deaths and Marriages Registration Act 1995 33-37
21-30 Human Tissue Act 1983 38-55
30-36 Anatomy Act 1977 56-70
37-39 Crimes Act 1900 71-77
39-40 Public Health Act 1991 78-79
40-78 Alleged Statutory Contraventions at Glebe 80-165
41-47 Long bones and joints 82-98
47-50 Unlawfulness of long bones and joints cases 99-103
50-56 Prof Hilton and research removals 104-115
56-70 Prof Hilton’s view of the purpose of post-mortem 116-143
examinations
70-78 Forensic experiments on donated bodies 144-165
78-87 Brains - Removal, Retention and Research 166-190
87-91 Alleged Unethical Practices at Glebe 191-201
91-95 Coronial Post-mortem Practices 202-211
95-102 Recommendations 212-213
95-97 Review of legislation §1-§11
97-100 Systems and administration §12-§26
99-102 Ethics §27-§34
Page
103-112 Appendix A
Lists of individuals and organisations who have supplied information, advice or
opinions in response to the Inquiry
113-114 Appendix B
List of individuals and organisations who made contact with or volunteered
information or views to the Inquiry
115 Appendix C
Call for public submissions
116-124 Appendix D
Expressions of opinion and attitude in press and broadcasting stories 2001, 1994
and 1992
125-128 Appendix E
Listing of TV, radio and press coverage
129-131 Appendix F
Complete list of allegations considered under the first and third terms of reference,
as notified to possibly affected persons
Appendix G
Confidential – Not to be published
Cases referred to in Report para 54
132-133 Appendix H
List of anonymized cases, indicating reported causes of death and parts removed
for research referred to in Report para 85
3
INQUIRY INTO MATTERS ARISING FROM THE POST-MORTEM
AND ANATOMICAL EXAMINATION PRACTICES OF
THE INSTITUTE OF FORENSIC MEDICINE
By Letters Patent dated 21st March 2001, under the authority of the
prerogative power of the State Executive, I was commissioned to conduct an inquiry
into matters arising from the post-mortem and anatomical examination practices of
the New South Wales Institute of Forensic Medicine, commonly known as the Glebe
Morgue. The terms of the Inquiry are to:
1. inquire into and report upon whether the Institute of Forensic
Medicine at Glebe under the directorship of Associate Professor John Hilton
had a prevailing practice of:
a) of removing tissue from deceased persons;
b) using such removed tissue; or
c) treating bodies,
in contravention of the Human Tissue Act 1983, the Anatomy Act 1977 or the
Coroners Act 1980; and
2. in particular, audit all management and clinical practices relating to
the removal of body tissue and organs in coronial post mortem examinations
at the Institute of Forensic Medicine at Glebe with regard to whether such
practices were necessary to determine the manner and cause of death; and
3. inquire into allegations of unethical practices at the Institute of
Forensic Medicine at Glebe; and
4. having regard to the findings relative to the above, make
recommendations as to:
a) any changes that should be put into place regarding the dignified
treatment of human bodies at the Institute of Forensic Medicine at
Glebe;
b) any further changes that should be put in place to ensure that the
wishes of the deceased persons and their next of kin are appropriately
taken account of in the conduct of post mortem and anatomical
examinations.
4
METHODS
2. I have been assisted enormously in the Inquiry by Ms Nicholle Nobel,
Principal Project Manager in the New South Wales Premier’s Department, Public
Sector Management Office, as Executive Officer.
3. Persons and organizations who have supplied information, advice or opinions
to the Inquiry in response to my requests are listed in Appendix A. Persons and
organizations who made contact with or volunteered information or views to the
Inquiry are listed in Appendix B. An advertisement inviting submissions from the
public was published on 30th April 2001 in The Sydney Morning Herald, The Daily
Telegraph and The Australian, in the terms noted in Appendix C.
4. The Minister for Health, the Hon Craig Knowles MLA, took the steps which
led to this Inquiry following publicity about alleged practices at the Glebe Morgue. In
particular, the Minister announced on 19th March 2001 that these steps followed
allegations, possibly including unlawful conduct by public health employees, made on
the Sunday television programme broadcast by the Nine Network on 18th March 2001.
A conspectus of the main press and broadcasting stories is set out in Appendix D. A
list of the publications from which these summaries were produced is set out in
Appendix E.
5. The nature and terms of the press and broadcasting stories are not merely
relevant as the immediate political context leading to the Inquiry. Because the topics
addressed by the Inquiry touch on questions of ethics, human dignity and
consideration of the wishes of deceased persons and their next-of-kin, public
5
sentiment so far as it can be gauged is directly relevant to them. I have tried to take
the expressions of opinion and attitude manifest in the press and broadcasting stories
into account without assuming that the factual premises upon which they have been
expressed are accurate or fair. In reaching my factual conclusions, I have not relied
on any statement which is to be found only in a press or broadcasting story without
substantiation elsewhere. On the other hand, in describing matters of public sentiment
or a range of popular opinion, I have certainly regarded the perceptions displayed in
press and broadcasting stories as evidence of those matters, while accepting that they
cannot be assumed to provide an accurate let alone complete reflexion of the actual
range of community opinions.
6. Given the focus on allegations of unlawful conduct, including criminal
offences, and given that this Inquiry is emphatically not a court or any other kind of
judicial process, I have tried to supply conclusions concerning the first term of
reference in such a way as to respect the presumption of innocence, the lack of any
power in this Inquiry to make binding determinations of fact or law, and the
sometimes critical rôle of informants’ or witnesses’ credibility.
7. The allegations referred to in the third term of reference and underlying the
first term of reference are not specified in them. Initially, their content was supplied
by the broadcast and printed journalism noted in 4 above. As the Inquiry proceeded, I
have received further written material directly from the informants who had already
provided the basis of those initial stories, and I have treated any extra criticism or
complaint about occurrences at the Institute as allegations to be considered under
these terms of reference. Next, I have taken the same approach to all other
correspondence, written submissions and interviews during the course of the Inquiry,
6
and thus the ambit and content of the allegations of unlawful or unethical conduct at
the Institute include matters raised by anyone in those ways.
8. This approach made necessary procedural safeguards to ensure that the content
and provenance of allegations was sufficiently made known to persons whose
interests (including reputation) might be adversely affected by conclusions about
those allegations. Throughout the Inquiry, I have regarded myself as bound to accord
such persons the protection and opportunity required in what I regard as comparable
circumstances by the High Court of Australia in Ainsworth v Criminal Justice
Commission (1992) 175 CLR 564. In the main, I tried to meet this standard by
providing such persons with copies of the documents (including extracts from
transcripts of interviews) containing material which conveyed or suggested all
allegations. As a further safeguard, in expressing conclusions in this Report about
allegations, I have ensured that no criticism or complaint is ruled on unless I was
satisfied that supporting material and the fact of an allegation had been made
available to the person in question.
9. As it happened, by dint of his being the Director of the Institute for most of the
period in question, it was Prof Hilton against whom most of the allegations were
made, and it was through his lawyers that most of the notifications referred to in 8
above were made.
10. The complete list of allegations I have considered under the first and third
terms of reference, as notified to possibly affected persons, is set out at Appendix F.
7
11. Some of the allegations I have considered, including some first aired on
television, were made by former members of staff at the Institute. In turn, some of
those informants are individuals who were very unfavourably commented upon by the
Independent Commission Against Corruption in its March 1998 Report on the
Investigation into the Glebe Morgue. In the main, ICAC’s investigation concerned
so-called ratting (ie stealing personal property from dead bodies under the control of
the coroner) and kick-backs from businesses in the funeral industry. These practices
have nothing whatever to do with this Inquiry. However, as noted in some of the
interviews recorded for television broadcast, and in other submissions to this Inquiry,
the background to and course of the ICAC investigation were obvious motives for
some of those informants to bear grudges against the Institute and its Director.
Accordingly, in every case where an allegation I have considered was made by a
person against whom a finding of corrupt conduct was made by ICAC or against
whom the ICAC Report records an adverse view of his or her honesty or credibility, I
have proceeded to seek corroboration in contemporaneous documents or (where
available) other persons’ information. In no case have I found that an allegation was
well-founded based solely on the word of any of these informants adversely named by
ICAC.
12. A number of responses to the Inquiry’s public invitation for submissions
raised strong grievances against the circumstances in which major organs or parts
(mostly brains) were removed and retained at the Institute, often involving complaint
about lack of prior consultation or even knowledge, and about insensitivity or
obfuscation after the event including arrangements for disposal of those body parts.
By and large, these submissions do not appear in Appendix F as allegations of