Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
PROGRAMME BOOK ASIA PACIFIC CORONERS’ SOCIETY CONFERENCE 2012
Contents
Welcome 3 Committee 3 Conference Programme 4 Conference Information 6 Social Programme Information 7 Speaker Profiles 9 The Debate 13 Hypothetical 13
ABSTRACTS Wednesday 21 November 14 10.00 am – Dr Peter Doyle Sydney: City of Shadows, From evidence to art: the forensic photograph as material culture 14 1.30 pm – Ms Belinda Baker Recent Developments in Coronial Law: A Discussion of Recent Coronial Law Decisions 14 2.15 pm – Chief Coroner Judge Neil MacLean An Inquisitorial Cuckoo in an Adversarial Nest: Five Years of Coronial Reform in New Zealand 14
Thursday 22 November 15 9.30 am – Forensic Psychiatry: Three views 15 View One – The effects of antipsychotic drugs –Dr Tim Lambert 15 View Two – Can psychiatrists meaningfully assess suicide risk? – Dr Matthew Large 15 View Three – Coronial Inquests: Friend or Foe? – Dr Michael Paton 15 11.30 am – A rock and a hard place: Asylum seeker deaths, Villawood and Christmas Island 16 Villawood Detention Centre – Magistrate Mary Jerram 16 Christmas Island – Mr Alastair Hope 16 Asylum seeking in Australia: The Impacts on mental health – A/Professor Suresh Sundram 16 The Commonwealth Ombudsman’s Perspective on the Immigration Detention Network – Ms Justine Jones 17
Friday 23 November 18 9.30 am – Dr Helen Paterson & A/Professor Richard Kemp What you get is not necessarily what you see: Eyewitness memory 18 10.15 am – Professor Wendy Hu & Mr Steve Linnegar Risks, Mistakes & Safety: The Human Dimension 18 11.45 am – Mr Bill Fittler Preventing Deaths In Custody – A Corrective Services NSW Perspective. Program in Prison: Pups and Art. 18
2 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
Welcome from Magistrate Mary Jerram
On behalf of the Asia Pacific Coroners' Society, I welcome you to our annual conference for 2012. We hope you enjoy the Amora Jamison Hotel and the social events being held at the Sydney Opera House and the MCA nearby. Everyone with an interest in coronial matters, coroners and staff, pathologists and other medical experts, minority groups, police, counsellors and lawyers, will find sessions of interest in the programme. Coronial practice is becoming of increasing interest to our community and attracting more and more media attention, whether we like it or not. In a civilised society, we are more and more open to comment and scrutiny. It is hoped that this conference will provide information, workshops and challenges to continue to meet those demands and to treat the dead and the bereaved with the dignity and investigation they deserve. Magistrate Mary Jerram State Coroner – New South Wales.
Committee
● Convenor – Magistrate Mary Jerram ● Magistrate Hugh Dillon ● Ms Cate Follent ● Magistrate Carmel Forbes ● Magistrate Sharon Freund ● Magistrate Paul MacMahon ● Mr Don McLennan ● Magistrate Scott Mitchell ● Ms Donna Schriever ● Mr Maurice Taylor ● Ms Ruth Windeler
Secretariat DC Conferences Tel: 02 9954 4400 Email: [email protected] Web: www.dcconferences.com.au
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Conference Programme All conference sessions will take place in the Whiteley Ballroom, on level 2 of the Amora Jamison Hotel.
Tuesday 20 November Wednesday 21 November
8.30am Registration desk opens 9.45am Welcome to Country 10.00am Sydney: City of Shadows Dr Peter Doyle
MORNING TEA 10.45am
10.30am – 4.00pm State Coroners Meeting 11.15am KEYNOTE ADDRESS Lindsay Room, Amora Jamison Hotel The role of the coroner and the rule of law The Hon Mary Gaudron AC QC
LUNCH 12.30pm
1.30pm Recent developments in coronial law: A discussion of recent coronial law decisions Ms Belinda Baker 2.15pm A review of the first five years of coronial reform in New Zealand Judge Neil MacLean
AFTERNOON TEA 2.35pm
3.00pm Registration desk opens 3.00pm OXFORD STYLE DEBATE: In a 21st century civilised Amora Jamison Hotel society the autopsy is an anachronism Facilitator: Dr Meredith Burgmann
5.00pm Welcome Reception 5.00pm Sessions close for the day Utzon Room, Sydney Opera House 6.00pm Welcome Address
4 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
Thursday 22 November Friday 23 November
9.30am Forensic Psychiatry: Three views 9.30am What you get is not necessarily what you see: Professor Tim Lambert, Dr Matthew Large, Eyewitness memory Dr Michael Paton A/Professor Richard Kemp, Dr Helen Paterson 10.15am Risks, mistakes and safety: The human dimension Professor Wendy Hu, Mr Steve Linnegar
11.00am 11.15am
11.30am A rock and a hard place: Asylum seeker deaths 11.45am Preventing deaths in custody – A Corrective Villawood and Christmas Island Services NSW perspective. Magistrate Mary Jerram, NSW State Coroner Programs in Prison – Pups and Art Mr Alastair Hope, WA State Coroner Mr Bill Fittler A/Professor Suresh Sundram, Psychiatrist Close of conference: Magistrate Mary Jerram Ms Justine Jones, Acting Senior Assistant Ombudsman
1.00pm 12.45pm
2.00pm HYPOTHETICAL 2.00pm Asia Pacific Coroners’ Society Panel: Mr Micheal Barnes, The Hon Prof Terry Buddin SC, Annual General Meeting Dr Matthew Orde, Dr Peg Dwyer, Dr Jane Mowll, Det. Supt Michael Willing, Professor Charles Naylor Moderator: His Hon Judge Ian H. McClintock SC
4.00pm
4.00pm Sessions close for the day
6.15pm Free Tour of the Old Coroner’s Court 104 George St, The Rocks, Sydney 7.00pm Gala Dinner – Harbourside Room, Museum of Contemporary Art, Circular Quay, Sydney
DISCLAIMER: The speakers, topics and times listed in this document are subjected to change. The organisers reserve the right to alter items in the programme or substitute speakers without prior notice.
5 ASIA PACIFIC CORONERS’ SOCIETY CONFERENCE 2012
Conference Information Break Times Morning and afternoon tea will be served within the Lounge Registration Desk area on level 2, outside the Whiteley Ballroom. Lunch will be On Tuesday 20 November the registration desk will be located served in The Gallery Restaurant on level 1. in the main foyer of the Amora Jamison Hotel from 3.00 pm – Wednesday 21 November 4.30 pm. The Conference Secretariat will also be present at the 10.45 am – 11.15 am Morning Tea Utzon Room, Sydney Opera House during the Welcome 12.30 pm – 1.30 pm Lunch Reception. 2.35 pm – 3.00 pm Afternoon Tea
During the conference, the registration desk will be located Thursday 22 November outside the Whiteley Ballroom on Level 2. 11.00 am – 11.30 am Morning Tea The opening times are: 1.00 pm – 2.00 pm Lunch Wednesday 21 November 8.30 am – 5.30 pm 4.00 pm – 4.30 pm Afternoon Tea Thursday 22 November 9.00 am – 4.30 pm Friday 23 November 9.00 am – 1.45 pm Friday 23 November 11.15 am – 11.45 am Morning Tea Staff at the registration desk will be happy to help with 12.45 pm – 1.45 pm Lunch any queries. Dietary Requirements Registration Entitlements If you have not already done so, please advise the Conference Full Registration includes: Secretariat of any specific dietary requirements and/or food ● Admission to all sessions allergies. If you have advised of a special diet request, please ● Conference satchel make yourself known to banqueting staff at the hotel in order ● Conference programme handbook to collect your special meal. Please note that vegetarians will ● Morning and afternoon teas and lunches on each day be catered for as standard. of the conference ● 1 ticket to the Welcome Reception Artwork Day Registration includes: The artwork displayed within the Whiteley Ballroom was ● Admission to all sessions on the day of your registration produced by the Girrawaa Creative Work Centre, a centre set ● Conference satchel up to provide greater employment opportunities for ● Conference programme handbook Indigenous people, and as a result of a programme by the ● Morning and afternoon tea, plus lunch on the day of Bathurst Correctional Centre to provide an outlet for cultural your registration expression for Indigenous minimum security inmates and provide a unique balance of cultural, educational, vocational, Day registration does not include a ticket to the workplace and business management skills for Aboriginal Welcome Reception, however these can be purchased at inmates. Girrawaa emphasises Indigenous strengths, the registration desk, for $85 per person. resiliencies & successes by reconnecting offenders with their culture. The artwork will be discussed during Mr Bill Fittler’s session, Friday 23 November at 11.45 am.
6 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
CLE Information Social Programme Information Seminars and other CLE activities are no longer accredited by the Law Society’s MCLE Board. Under the new guidelines, if Welcome Reception this particular educational activity is relevant to your Utzon Room, Sydney Opera House immediate or long term needs in relation to your professional Tuesday 20 November 2012, 5.00 pm – 7.00 pm development and practice of the law, you should claim one Dress: Business attire “unit” for each hour of attendance, refreshment breaks not Additional ticket price: $85 per person included. The annual requirement remains unchanged at ten The Welcome Reception is included in the registration fee for (10) MCLE units each year from 1 April to 31 March. full registrants and includes canapés and drinks.
Speaker’s Preparation Desk Collect your name badge between 3.00 pm - 4.30 pm at the All presenters must check-in at the Speaker’s Preparation registration desk, located in the main foyer of the Amora Desk, outside the Whiteley Ballroom on level 2 at least 2 hours Jamison Hotel and head down to the Sydney Opera House's prior to the start of their session time. Presentations must be iconic Utzon Room for the Welcome Reception and start of brought on either USB memory stick or CD. the 2012 Conference. This is the perfect chance for delegates to mingle with friends Mobile Phones and colleagues.
As a courtesy to fellow delegates and speakers please ensure Convenor Magistrate Mary Jerram and Her Excellency that your mobile phone is switched to silent or turned off Professor Marie Bashir AC CVO, Governor of New South Wales, during all conference sessions. will officially welcome delegates at 6pm.
Conference Feedback A post-conference report is an important aspect of the Utzon Room conference as it ensures sustainability of the event as well as making sure the content is always relevant and up to date. You will be emailed a link to the evaluation at the conclusion of the conference.
The Utzon room is located under the monumental steps on the east side of Sydney Opera House. It can be accessed by walking under the monumental steps of the House and along the concourse. Utzon room is the second door to your left after you’ve passed Stage Door.
7 ASIA PACIFIC CORONERS’ SOCIETY CONFERENCE 2012
Old Coroner’s Court Tour Gala Dinner
Thursday 22 November, 6.15 pm Thursday 22 November, 7.00 pm – 11.30 pm Craft NSW, 104 George Street, The Rocks Harbourside Room, Museum of Contemporary Art (MCA) Complimentary Event Dress: Cocktail Ticket price: $100 per person A tour has been organised for all delegates and accompanying people of the Old Coroner’s Court. The tour Located on the rooftop of the MCA, the Harbourside Room will take place prior to the Gala Dinner. The building was built has floor to ceiling glass doors which open onto a private in 1854 as a morgue and later demolished in 1906. In 1907 the outdoor terrace. This venue provides uninterrupted views present Coroner’s Court was constructed. It is the earliest across Sydney Harbour, the Opera House and Harbour Bridge. surviving Coroner’s Court in NSW. The style is Federation Free An exquisite 3-course dinner will be served along with a fine and highlights the architect’s concern and ability to design for selection of beverages and there will also be light function and Sydney’s weather. entertainment provided.
Delegates can enjoy an after-hours walk through this The list of attendees will be displayed on a message board, historical building before heading to the Gala Dinner, just a located adjacent to the registration desk at the Amora short stroll away. Jamison Hotel. This is a ticketed event. Should you wish to purchase a ticket, please visit the registration desk immediately. Please contact the Conference Secretariat if you are unable to attend; unfortunately there are no refunds offered.
1 Amora Jamison Hotel, 11 Jamison Street, Sydney 2 Utzon Room, Sydney Opera House 3 Museum of Contemporary Art
8 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
Speaker Profiles Mr Bill Fittler Mr Bill Fittler is the General Manager of Keynote Speaker: Bathurst Correctional Centre Cluster and leads the management of this The Hon Mary Gaudron, AC QC complex and diverse operation The Hon Mary Gaudron, AC QC, an Australian lawyer and involving a remand and minimum- retired judge, was the first female Justice of the High Court of security correctional centre at Bathurst, Australia. In a groundbreaking career, Ms Gaudron a variable security centre at Cooma, passionately championed gender equality and Indigenous and a court escort and security unit at rights, ruling on landmark decisions such as Mabo and Wik. Queanbeyan. The cluster houses 769 offenders, with a team of She also appeared in the Equal Pay case for the Whitlam over 280 staff and manages a budget of over $32 million. Government. Mr Fittler’s previous experience includes twelve years as Invited Speakers: governor, Regional Superintendent and now General Ms Belinda Baker Manager with Corrective Services; and previously Regional Manager and Area Manager with National Parks and Wildlife Ms Belinda Baker is a Solicitor Advocate Service and Catchment Manager with Department of Land in the NSW Crown Solicitor’s Office. She and Water Conservation. frequently appears as counsel assisting the coroner in inquests and inquiries in Mr Alastair Hope NSW, in the coronial jurisdiction on Mr Alastair Hope was first admitted as a behalf of interested parties; and on barrister and solicitor on 30 January, behalf of the NSW Attorney General in 1976. He practised for over 20 years, Supreme Court appeals and reviews appearing as leading counsel on many concerning coronial decisions. major trials and appeals within the Ms Baker is a co-author of the 4th edition of Wallers Coronial High Court, Courts of Criminal Appeal, Law and Practice in NSW (LexisNexis, 2010); and the author of Full Courts and Supreme Courts. the Coroners Title in Halsbury’s Laws of Australia. Belinda Mr Hope was appointed as State holds a Master of Laws from Harvard University (2004), which Coroner of Western Australia in 1996. As State Coroner, he has she attended as a Menzies Scholar. conducted a large number of inquest hearings where
Dr Peter Doyle comments and recommendations on safety and health issues have resulted in significant improvements. Dr Peter Doyle is a lecturer, author and musician. He has worked as a part-time Recent inquest hearings conducted by Mr Hope, which have curator at the Justice and Police attracted considerable public interest, include an inquest held Museum in Sydney where he curated in 2007 and 2008 into 22 alcohol and drug related deaths in the exhibitions “Crimes of Passion” and the Kimberley which included 17 deaths by suicide and the “City of Shadows”. This work led to the recent inquest into the death of Mr Ward who died in the rear publication of City of Shadows: Sydney pod of a prison van in 2008. police photographs 1912-1948.
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Professor Wendy Hu Ms Justine Jones Professor Wendy Hu (MBBS (Hons) Ms Justine Jones is a Senior Assistant MHA PhD FRACGP) was appointed Ombudsman at the Office of the Professor of Medical Education and Commonwealth Ombudsman. She has Director of Academic Programs at the an extensive background in policy School of Medicine, University of implementation from her career as a Western Sydney in 2012. Prior to this public servant in a number of she was a senior academic in General Commonwealth Government Practice, and Associate Director of agencies. Since joining the Education at The Children’s Hospital at Westmead. Ombudsman’s Office at the beginning of 2011, Ms Jones has focused on improving public administration through the Professor Hu has worked as a clinician in a variety of investigation and review of administrative actions in a community and hospital healthcare settings and experienced number of portfolios including human services and defence. first-hand the dilemmas that healthcare practitioners face. Her In her current role, she is responsible for immigration and current research interests include judgment and decision overseas students, which includes the oversight of making in clinical practice; in particular how clinical immigration detention in Australia though regular inspections supervisors judge the safety and competence of students and of detention facilities and a statutory function to report on the trainees in patient care. detention arrangements of each person detained for longer Magistrate Mary Jerram than two years. Magistrate Mary Jerram is the State Associate Professor Coroner of New South Wales. She was Richard Kemp appointed on 3 May 2007 and is the first female to hold this position. Prior Associate Professor Richard Kemp is to this appointment, Magistrate Jerram director of the Master of Psychology had a career as a teacher, union (Forensic) programme at University of advocate and legal aid solicitor. Her New South Wales. His background is in Honour was appointed as a Magistrate experimental and applied cognitive in 1994 and became Deputy Chief Magistrate of the Local psychology. He was awarded his PhD Court of New South Wales in 2000. Whilst the Deputy Chief from University College London in Magistrate, Magistrate Jerram provided advice with regards to 1995. His research focuses on the application of cognitive legislative and other proposals of assistance to the New South psychology to the legal system. Wales Government and also education for other magistrates. Current research projects cover topics including eyewitness memory and eyewitness identification, photo ID cards, forensic science and expert evidence, and the effectiveness of prison based treatment programmes for offenders. A/Professor Kemp currently holds three ARC Linkage Grants with Department of Foreign Affairs and Trade, WorkCover NSW and NSW Fire Brigade. In addition to his journal publications, he has published three psychology textbooks including a bestselling guide to statistics, which is now in its 5th edition.
10 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
Professor Tim Lambert Judge Neil MacLean Professor Tim Lambert is Professor of District Court Judge Neil MacLean was Psychiatry at Concord Clinical School, appointed the first Chief Coroner of The University of Sydney. He is also New Zealand under the Coroners Act Head of Schizophrenia Treatment and 2006 and has since worked closely with Outcomes Research at the Brain & the government and professional and Mind Research Institute in Sydney. community groups in relation to the Professor Lambert also fulfills clinical appointment and disposition of duties for the Sydney South West Area Coroners throughout New Zealand. Health Service as Director of the Centre of Excellence in Prior to this, Judge MacLean assisted in the preparation of the Relapse Prevention in Psychosis, and at the Concord Centre for Coroner's Manual 1988 and provided consultative information Cardiometabolic Health in Psychosis. to the Chief Judge regarding the Coroners Act 2006. He has been a principal in the development of a number of clinical practice guidelines, algorithms, and consensus Dr Helen Paterson documents. Currently, he is chairing the consensus Dr Helen Paterson is a Lecturer in development group for treatment-resistant schizophrenia. Forensic Psychology, The University of Professor Lambert is a regularly invited lecturer, clinical trainer, Sydney. Her primary research interest and industry consultant throughout Asia, Australia, Europe, focuses on the effects of discussion and North America. amongst witnesses on the accuracy of their individual memories. She Dr Matthew Large obtained her PhD at The University of Dr Matthew Large is a practising New South Wales in 2005. While clinician with a research interest in the completing her PhD, Dr Paterson also gained valuable work epidemiology of homicide and suicide. experience in applied, forensic settings, including the New He has published more than 40 papers South Wales Crime Commission and New South Wales Police. on the topic of risk assessment in Her latest research endeavour is to examine the impact mental health. of post-incident debriefing amongst emergency service personnel on their psychological well-being and recall of events. Mr Steve Linnegar Mr Steve Linnegar is the Executive Dr Michael Paton General Manager of Syntheo, a joint Dr Michael Paton is the Clinical Director venture between Lend Lease, a listed of the Mental Health, Drug and Alcohol property group specialising in project Service, Northern Sydney Local Health management, construction, real estate District, which provides public sector investment and development, and mental health and Drug and Alcohol Service Stream, one of Australia’s services to a population of largest telecommunications approximately 900, 000 people. His infrastructure specialists. He is responsible for construction of current role includes responsibilities for the National Broadband Network in Western Australia, South the oversight of components of the clinical governance of the Australia and the Northern Territory. Until recently, he was the service, including clinical safety and quality, management of Head of Risk for Lend Lease’s construction and engineering the senior and junior medical workforce, and service and business in Australia. clinical model of care development for new and existing mental health and drug and alcohol services in the Northern Sydney Local Health District.
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He has worked for over 25 years in the public health sector in NSW, in a diverse range of mental health service settings but with a focus on mental health service provision for people with severe, complex and enduring disorders both as a clinician and administrator. He is a member or chair of a number of Northern Sydney Mental Health and Drug and Alcohol service committees, as well as Local Health District, Royal Australian and New Zealand College of Psychiatry and NSW Ministry of Health Committees. He has published in a number of areas pertinent to mental health system and clinical service analysis.
Associate Professor Suresh Sundram Associate Professor Suresh Sundram is the Head of Molecular Psychopharmacology at the Mental Health Research Institute, Director of The Northern Psychiatry Research Centre and Director of Clinical Services of the Northern Area Mental Health Service.
He is actively involved in neurobiological and clinical research into schizophrenia and related psychotic disorders with over 60 publications in the area. He is an Associate Professor with the Department of Psychiatry at the University of Melbourne. In addition, he has worked with asylum seeker and refugee populations within the community and in immigration detention centres where he was the external consultant on mental health to the Australian Human Rights Commission and has researched and published on the mental health effects of asylum seeking in Australia.
12 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
The Debate Hypothetical
Wednesday 21 November 2012 Thursday 22 November 2012 3.00 pm - 5.00 pm 2.00 pm – 4.00 pm
The Motion: Topic will be announced at 2.00 pm In a twenty first century civilised society the autopsy is an A panel of diverse experts – from the medical, legal, social, anachronism. judicial and policing fields will attempt to reach a consensus or at least a decision, on what is to be done in the critical This session will be an educative tool that looks at the issues coronial situation put to them by Sydney’s Mr Ian McClintock. surrounding this complex area. Rather than determine the issue, it is not proposed to take a final vote on the motion. The The Moderator debate will last for 60 - 70 minutes, with each speaker having 10 minutes to present. Summing up, Dr Burgmann will ● His Hon Judge Ian H. McClintock SC, District Court undertake a short review of the issues raised during the of NSW course of the debate. Statements and questions will also be The Debate taken from the floor. ● Mr Michael Barnes, Queensland State Coroner ● The Hon Prof Terry Buddin SC, NSW Supreme Court The Faciliator Judge (retired) and Prof of Law, University of Wollongong ● The Hon Dr Meredith Burgmann, Former President, ● Dr Peg Dwyer, Barrister, Forbes Chambers Legislative Council of New South Wales ● Dr Jane Mowll, Grief Counsellor, Glebe, NSW The Affirmative Team ● Professor Charles Naylor, Senior Forensic Pathologist, Qld ● Mr Graham Segal OAM, Barrister, Second Floor, ● Dr Matthew Orde, Senior Forensic Pathologist, Selbourne Chambers, Sydney Department of Forensic Medicine, NSW ● Ms Helen Roberts, NSW Crown Prosecutor, Parramatta ● Detective Superintendent Michael Willing, Head of Homicide, NSW Police ● Associate Professor Ian Kerridge, University of Sydney
The Negative Team ● Dr Peter Smart, Pathologist, Wagga Wagga ● Ms Margaret Cunneen SC, Deputy Senior Crown Prosecutor, Sydney ● Dr Ian Freckleton SC, Barrister, Crockett Chambers, Melbourne
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ABSTRACTS 2.15 pm – Chief Coroner Judge Neil MacLean An Inquisitorial Cuckoo in an Adversarial Nest: Wednesday 21 November Five Years of Coronial Reform in New Zealand 10.00 am – Dr Peter Doyle In 2000 a Law Commission report raised concerns about inconsistency, delay, lack of sensitivity and lack of Sydney: City of Shadows, coordination in the coronial process in New Zealand. In its first From evidence to art: the forensic photograph as 5 years, the fledgling reformed system has been tested by a material culture number of obstacles, including several major tragedies. There Some thousands of photographs -- crime and accident scenes, also remain a number of ongoing areas of contention. This objects and offender portraits -- held in the Forensic presentation explores the developments, achievements and Photography Archive at Sydney’s Justice & Police Museum shortfalls of the last 5 years of coronial reform in New Zealand have made the transition from grim, restricted, purely and the extent to which these concerns have been addressed. operational and procedural accouterments to popular, valued national historico-aesthetic artifacts. This seemingly unlikely The role that the Coroner’s inquest should play in the context transformation might be seen within a larger historical cultural of other investigations and overlapping jurisdictions context, by which purely forensic narratives and artifacts continues to be debated. Recently, the Kahui case generated a become widely-trafficked cultural property, and may even large amount of discussion about the appropriate scope of become enshrined as elements of our national mythologies. the Coroner’s inquest in the context of inconclusive criminal proceedings. The reporting of suicide within NZ’s strict In this presentation, Dr Doyle will discuss a selection of statutory regime is another issue that continues to be forensic images which reveal hitherto little known aspects of contested in a background of a high national suicide rate that mid twentieth century Sydney and the lives of its citizens. has remained stubbornly the same. In other areas, the
1.30 pm – Ms Belinda Baker absence of clarity in the Act and lack of precedential case law has left a number of matters untested. There is very little Recent Developments in Coronial Law: A Discussion recent case law before the High Court on coroners’ decisions of Recent Coronial Law Decisions and despite earlier predictions, no objections to post-mortem Ms Baker’s talk will cover recent superior court decisions that decisions have yet gone to the High Court. In the absence of are of interest and relevance to coroners. In particular, Ms any statutory guidance, coroners also await the Supreme Baker will address recent superior court decisions concerning Court’s handling of the Takamore case to assist in the a coroner’s decision as to whether to hold an inquest, the resolution of body claiming disputes. content of findings concerning “cause and circumstances” and the extent of a coroner’s duty of procedural fairness. Notwithstanding these challenges, the reformed system continues to make positive advances and the findings and Ms Baker will also discuss the recent decision of the High recommendations of coroners are gaining increasing publicity Court in Burns v The Queen [2012] HCA 35, which concerns the and attention. The coronial system proved its ability to cope law of manslaughter by criminal negligence. Burns v The with major disasters such as the Christchurch earthquake, Pike Queen is of relevance to coroners who must decide whether River mining disaster and Carterton balloon tragedy. However, or not to refer charges to the Director of Public Prosecutions in it is clear that there are areas where the coronial system could inquests following deaths resulting from a drug supply. be further streamlined and enhanced. An upcoming review of the coroners’ Act may take some steps toward this. Other potential areas of reform include the concept of mandatory responses to coroners’ recommendations, the establishment of a Coroner’s Court of New Zealand and further development of the law surrounding what deaths should be reported to a coroner.
14 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
Thursday 22 November View Two – Dr Matthew Large 9.30 am – Forensic Psychiatry: Three views Can psychiatrists meaningfully assess suicide risk? View One – Dr Tim Lambert Coroners and mental health professionals view suicide from The effects of antipsychotic drugs opposing directions. Suicide inquiries are part of the everyday activities of a coroner and the roles of the coroner include the Having a mental illness has long been - and remains - a barrier determination of the cause of death and the elucidation of to receiving good medical care. People with severe and possible contributory circumstances. In contrast, the role of enduring mental illness, predominantly those with psychosis, the psychiatrist is to treat and assist patients with mental are prey to a ‘double whammy’ of disability that ensues from illness, few of whom will ever commit suicide. This paper this. On top of having a horrendous psychiatric illness they are summarises the existing scientific literature about the ability likely to die in their 50’s from (largely preventable) of mental health professionals to prospectively categorise cardiometabolic disease and other consequences of their patients as being at higher or lower risk of suicide during a illness and - not surprisingly – their treatments (or their psychiatric admission or after discharge from a psychiatric absence). Currently up to 25 years of life are lost through hospital. While it is possible for some suicides to be premature mortality. understood in retrospect, the evidence suggests that mental Although the reasons for the latter are complex, there are a health professionals are not able to make useful judgments number of factors that contribute to this state which are about the future suicide of mentally ill patients. potentially iatrogenic in nature, compounded by entrenched societal neglect. One such group of factors are those View Three – Dr Michael Paton stemming from psychotropic (mis) use, especially the Coronial Inquests: Friend or Foe? – antipsychotic class of medicines. Deaths of patients whilst receiving care from mental health In this talk the role of antipsychotic medication in cases of services are extremely distressing for all involved. The desire to premature or unusual death in persons with severe mental investigate, to understand what has occurred, to determine illness will be presented. The issues of concern to coronial staff who should be held accountable and to rectify systematic will be explicated within a framework of cases that should be issues contributing to the death are understandably of great immediately recognisable. Cases will be exemplars of importance to the bereaved, clinicians, service leaders, situations that involve psychopharmacological mechanisms administrators and Health Departments. Such deaths are contributing to death and will cover cardiometabolic health usually referred to the Coroner in NSW for consideration, with (‘diabesity’, cardiac disease, sudden death), neurological issues high community expectations in a civilised society that (severe akinetic and dyskinetic motor side effects), as well as appropriate action will then be taken. common situations associated with inadequate investigation In previous decades some coronial recommendations were of known risks that can be predicted from basic made that specific actions be taken across all the State’s pharmacotherapeutic principles (inadvertent overdoses in mental health services on the basis of findings of the review of cachectic women, for example). a single death, usually a suicide, albeit in the context of other Coronial investigation of premature death in this population deaths in similar circumstances. Whilst such will be increasingly important in the coming years, and an recommendations were logical within the context of the case understanding of how antipsychotic treatments may under consideration, the complexity and diversity of health contribute to this issue will hopefully benefit the process. services in which the recommendations were required to be implemented is marked. As such, the goal to prevent similar tragedies in future is often unmet, with potential diversion of health resources in some circumstances to compliance activity with little demonstrable benefit for patient care or suicide prevention. More recently, such specific coronial recommendations are rarely made in NSW due to improved
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acute public sector mental health services, the development deceased person whose body was recovered. Evidence of Federal and State suicide prevention initiatives and more comprised accounts of witnesses including survivors of the rigorous incident review at the Local Health District level. disaster, family members in Australia and overseas and other Unfortunately, adverse events in mental health care settings witnesses. DNA evidence was used in many cases as proof of and service continue to occur, although there is encouraging identity. In a number of cases dental evidence was obtained evidence that suicide rates are decreasing in NSW and across from the countries of origin and dental comparisons provided Australia. conclusive evidence as to identity. All 30 deceased persons were identified to the satisfaction of the State Coroner or In these changing circumstances then, what Deputy State Coroner. recommendations should a coroner make when reviewing a mental health related death? Investigating and understanding In respect of the deceased persons whose bodies were not what has happened, accountability for it and identification of recovered, the process was much more complicated. Again in systems deficiencies are still required. How can the coronial each case a separate file was created, largely as a result of and health systems coordinate effort and efficacy in this investigations conducted by the Australian Federal Police. regard to achieve the greatest societal benefit? This Unfortunately in some of these cases the evidence initially presentation shall attempt to address some aspects of this presented was not sufficient to provide proof of identity and complex challenge, from the perspectives of health services’ further investigations were conducted by WA Police. experience, clinical governance and some research. None of these cases was reviewed by a DVI Identification Board. 11.30 am – A rock and a hard place: Asylum seeker deaths, Villawood and Christmas Island The investigation into the circumstances surrounding the incident was extremely extensive and a large number of Magistrate Mary Jerram issues were raised by a range of different individuals and Villawood Detention Centre parties. The ultimate brief prepared by WA Police contained 25 NSW State Coroner, Magistrate Jerram will be introducing this annexures, each annexure comprising multiple lever arch files. session. In 2011, Magistrate Jerram held a long inquest into Annexure 2, for example, comprised 9 lever arch files. The total three suicides at Villawood Detention Centre, at the end of brief comprised well over 100 lever arch files. which a fourth suicide occurred in the same centre. A/Professor Suresh Sundram Mr Alastair Hope Asylum seeking in Australia: The Impacts on Christmas Island mental health On 15 December 2010 a suspected illegal entry vessel crashed The United Nations High Commissioner for Refugees on the rocky shoreline of Christmas Island as a result of which estimated approximately 441,300 claims for asylum were 50 passengers died. Subsequently the bodies of 30 of those lodged in industrialised nations in 2011. Of these, 11,500 were persons were recovered, in respect of 20 persons who died lodged in Australia, representing 2.6% of total claims. Despite their bodies were never recovered. The Coroner’s Court was this comparatively low number, asylum seekers to Australia required to respond to this disaster immediately and have attracted considerable political and media interest continuously for the remainder of the year and beyond. The especially since 2001. In particular, irregular maritime arrivals disaster attracted attention on the world stage and there was have been subjected to a range of measures aimed at a requirement to deal with aspects of the incident deterring their arrival such as mandatory detention, expeditiously (aspects of this matter will be discussed later in temporary protection visas and off-shore processing. this Overview). Even with policy changes mandatory detention has remained Following the disaster on 15 December 2010 it was necessary enforced and is indefinite. These peculiar characteristics place for the deceased persons to be identified. 30 separate asylum seekers at especial risk of developing mental illness, identification files were prepared, one in respect of each including major depression, post-traumatic stress disorder
16 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
(PTSD) and related disorders. There has been little opportunity time in detention and feelings of hopelessness; uncertainty to investigate the effects of immigration detention, however about the future; anxiety over being unable to earn money our research of community based asylum seekers and concern for families remaining at home; uncertainty and demonstrate very high levels of these disorders and a confusion over the immigration process and the status of their relationship between PTSD and the refugee determination claims for protection; delay in processing claims and the process. Encouraging however, is the observation that living in consequences of these delays on physical and mental health. the community, even without specific mental health Through the course of our oversight role we have noted interventions nevertheless results in improvements in these higher levels of discontent and frustration when the detention disorders. As such, attempts to move asylum seekers into network is under strain, due to increased numbers of people community environments are likely to have positive benefits in detention and high numbers of people detained for on mental health. In stark contrast is the observational data lengthy periods of time. The Government policy, in November that those kept in prolonged detention experience a 2011, to grant Bridging Visas and release people into the deterioration in their mental state culminating in some cases community after initial processing has had an impact by of psychosis and suicide. The recent re-introduction of off- decreasing the average period spent in detention but there shore processing and continued mandatory indefinite remain a large number of people in detention for longer than detention do not augur well for the mental health of asylum three months. seekers.
Ms Justine Jones The Commonwealth Ombudsman’s Perspective on the Immigration Detention Network The Commonwealth Ombudsman conducts a range of activities as part of the oversight and review of immigration detention. This includes a statutory role to report to the Minister for Immigration and Citizenship on the appropriateness of the detention arrangements for each person held in immigration detention for two years and at subsequent six-monthly intervals. The inspections visit programme introduced in 2008 is at the core of our oversight function. We aim to visit each facility in the immigration detention network at least twice each year. This provides an opportunity to conduct complaint clinics and information sessions, interview people detained for more than two years (who are the subject of our statutory reports), inspect the detention facilities, and discuss operations with Department of Immigration and Citizenship and its service providers. The review of detention arrangements of individuals and the investigation of complaints from detainees often highlight mental health issues, attempted self-harm, past torture and trauma, treatment for depression including counselling and medication, voluntary starvation and other forms of protest, and poor behaviour which may be a result of living in a closed environment for lengthy periods. Common issues raised by detainees with the Ombudsman include: concern at length of
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Friday 23 November 11.45 am – Mr Bill Fittler 9.30 am – Dr Helen Paterson & A/Professor Preventing Deaths In Custody – A Corrective Richard Kemp Services NSW Perspective What you get is not necessarily what you see: Program in Prison: Pups and Art Eyewitness memory Corrective Services NSW (CSNSW) is responsible for managing While most of us commonly assume that our memories about the largest correctional system in Australia. As at 2 September personally witnessed events are accurate and trustworthy, this 2012, CSNSW was managing 9,617 full-time offenders, 17 is often not the case. Many psychologists argue that periodic detainees and approximately 16,589 offenders in the eyewitness memory is not as reliable as the layperson may community. believe. In this session Dr Paterson and A/Prof Kemp will The offender population is diverse and numbers fluctuate discuss the characteristics and limitations of human memory significantly as reflected in the numbers remanded in 2010/11 at three stages: acquisition/encoding, storage, and retrieval. at 10,876 and the total number of receptions into custody for Participants in this session will take part in a series of activities 2010/11 being 27,926. Sheer numbers pose considerable designed to illustrate the difficulties faced by eyewitnesses management challenges for meeting the needs of offenders which can result in poor reliability of their evidence. Dr and especially the special needs for those at risk of suicide Paterson and A/Prof Kemp will summarise psychological and/or have mental health issues. research regarding factors that influence eyewitness In 2010, the National Prisoner Health Census identified that testimony with a view to helping legal practitioners 31% of prison entrants reported that they had been told by a understand the limitations and vulnerabilities of eyewitness health professional that they had a mental health disorder, evidence. and in CSNSW, research by BMC Public Health found that one- 10.15 am – Professor Wendy Hu and third of offenders reported lifetime suicide ideation and one- Mr Steve Linnegar fifth had attempted suicide. Risks, Mistakes & Safety: The Human Dimension Deaths in Custody in CSNSW for 2010/11 amounted to 20, Uncertainty and mistakes are a normal part of the human comprising 9 by natural causes, 10 by apparent unnatural condition but can lead to catastrophe. Those working in the causes (suicide) and 1 where the cause is yet to be coronial jurisdiction see the results of such catastrophic determined. failures. Using critical examples from real life, this session will Coordination of programs and policy are undertaken in line focus on problems of risk, uncertainty, mistakes as they relate with national and state frameworks, and CSNSW has taken to medical diagnosis and treatment, and the difficulties of further initiative by establishing a “Management of Deaths in protecting patients from errors at each stage of decision Custody Committee”. The committee ensures a collaborative making, response and action. The “science” of human factors and proactive approach to management of coronial inquiries, has grown up around repeated instances of system failures reports and recommendations. and subsequent attempts to build process driven protections against failures in complex and risky activities. What can we The high prevalence of suicide risk factors among offenders learn from examining such failures from the different complicates the task of identifying those offenders at most perspectives of medicine and the construction industry? This risk of attempting suicide. CSNSW has taken a multi level session aims to stimulate discussion and debate about the approach to developing and implementing programs for “At utility of systematic approaches to mitigate risk where human Risk Inmates”. values and interactions are at stake. Bathurst Correctional Centre developed a specialist At Risk Therapeutic Group Program for the high proportion of cognitively impaired, brain injured or learning disability offenders that are housed in Acute Crisis Management Units.
18 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
The program involves group therapy sessions and the The ability of animals to provide positive regard and to not therapeutic manager has included outdoor activities with discriminate against people makes them a unique medium exercise, gardening, and interaction with a “therapy dog” to for increasing self esteem. assist participation and engagement of the offenders. The Pups-in-Prison Program is currently being scoped to Bathurst Correctional Centre has taken significant efforts to provide therapy dogs for defence veterans, “Dogs for Diggers”, improve the overall care of offenders and reduce the returning with physical and mental health injuries from recent incidences of suicide by introducing multi-disciplinary reviews peacekeeping activities in Afghanistan and other defence of offenders at risk, using observation cells and CCTV, force activities. installing appropriate cell furniture, reducing risk of self harm and removal of hanging points, and implementing Transition or Buddy cells for offenders to be housed in two-out cells.
The bulk of programs and services at Bathurst Correctional Centre have been aimed at “primary prevention” with the provision of structure, purpose and engagement of offenders through meaningful employment, programs and education, and providing an improved environment that reduces stress and stressors. Specialised offender programs unique to Bathurst have been implemented such as the Girrawaa Creative Work Centre and the Pups-in-Prison Program.
The Girrawaa Creative Work Centre originated as a response to the recommendations made by the Royal Commission into Aboriginal Deaths in Custody to provide greater employment opportunities for Indigenous People, and as a result of a program by the Bathurst Correctional Centre to provide an outlet for cultural expression for Indigenous minimum security inmates. Offenders produce high quality art works and undertake education and business studies. The Centre is located close to, but separated from, the main Bathurst Correctional Centre.
Pups-in-Prison Program commenced at Kirkconnell Correctional Centre in 2002 and was transferred to Bathurst Correctional Centre in 2011.
The Pups-in-Prison Program at Bathurst Correctional Centre has since been redeveloped into an integrated program that involves canine training and associated community interaction, but also a cognitive behaviour program for the offenders. This unique program draws extensive work in USA for Approaches to Incorporating Animals into Mental Health Therapy Interventions.
Therapists can extensively facilitate and utilise attachment to an animal for therapeutic purposes. Many clients in therapy suffer from low self-esteem.
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20 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
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22 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
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23 Silent Witnesses: The place of the coronial system in a civilised society Amora Jamison Hotel, Sydney | 20 – 23 November 2012
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