It wasn’t until the early 1990s that a number of authorities were moved to protest vehemently enough about Dr Manock’s work that action was taken. A series of shocking events faced doctors and police. The brutal deaths of three innocent babies, within the space of 18 months, was distressing enough. All three showed unmistakable signs of serious and prolonged abuse. Between them they had numerous broken bones, bruises and possible cigarette burns. Dr Manock, who conducted the three individual autopsies, found each infant had died of bronchopneumonia, an inflammation of the lungs. The death certificates were marked ‘death by natural causes’.
Parts of Smithfield at that time were as close to being a public housing ghetto as you might find. The northern suburb’s shabby streets were filled with squat red-brick houses with stained corrugated-iron roofs. Many of the yards comprised a mass of gravel and weeds, strewn with rusting car bodies, broken furniture and dismembered children’s toys. This was the physical face of a social welfare wasteland.
It was in this environment that the first of the tragic trio – Storm Deane, barely three months old – struggled for life. On the morning of 15 October 1992, Storm’s father, Craig Deane, had been in the backyard shed tinkering with a motorcycle. He was later joined by Storm’s mother, Heather Piggott, who described herself as a telemarketer. The baby had been left sleeping inside their Smithfield Plains housing trust home.
Heather Piggott later told the authorities that when she went inside to check on Storm she found he wasn’t breathing. She screamed for Craig to come. He burst through the door to find Storm turning blue and attempted to resuscitate him while Heather called for an ambulance. When it arrived Craig ran to meet the paramedics hugging Storm to his chest. He tripped on an uneven cement step and fell to his knees but kept the baby’s head from hitting the path. It was an act of tenderness that appeared to have come too late.
Suspicion over baby Storm’s death firmed when Dr Richard Burnell of the Women’s and Children’s Hospital discovered swelling on his brain. Doctors who attended the infant believed he had suffered two skull fractures. Further concerns were aroused by Craig Deane’s angry outbursts towards Heather while Storm hovered on life support in the intensive care unit. Consultant histopathologist Dr Roger Byard was sufficiently disturbed by what he’d heard and saw to order a full-body X-ray based on the possibility that Storm was a battered baby. When his life support was turned off his little body revealed a tapestry of ulcers and bruising. His back was scarred, his ribs bore a mass of fractures and his fragile head was splintered with two linear fissures. The injuries stirred Dr Byard’s suspicions about homicide. The X-rays of these ‘fingerprints’ of abuse had accompanied the body to the Forensic Science Centre for Dr Manock’s autopsy. He later reported removing the skull cap and, while holding it up to the light, saw nothing. He chose not to engage the assistance of a skilled radiologist to check his observations.
The second victim was nine-month-old William Barnard, who was pronounced dead on 31 July 1993. The ambulance officer who attended the scene recognised William’s mother, Cherry Lee, from a trip two years earlier when he’d picked up another dead child. On that trip the deceased had been her daughter, Cassie, whose death was attributed to sudden infant death syndrome. On this occasion the paramedic’s suspicions were provoked by the sense of vague detachment Cherry Lee displayed during questioning and even when William’s body was being placed in the ambulance. The father, Dave, was nowhere to be seen. William’s body, like Storm’s, showed the unambiguous signs of abuse. He was a patchwork of bruises, scars and facial wounds, and had suffered two factures to his spindly right arm.
The third baby was Joshua Nottle, nine months old. His parents, Julieanne and Sean McCluskey, were separated but shared the same accommodation. Julieanne had taken up with a new boyfriend, Ashley Pope, and this enraged McCluskey. The day before Joshua’s death McCluskey had attacked his former de facto but by that evening things seemed to have settled down. At least that’s the story they told. Overnight, Joshua had a disturbed sleep, waking several times in his cot in the living room, where Sean was also bedded down. It was he who had attended to the troubled infant during the night. The next morning Joshua was found facedown in his cot. An alarmed Julieanne rushed to pick him up and found him limp and lifeless.
Sean drove mother and child to the Modbury Hospital while she attempted to resuscitate Joshua in the back seat. Joshua was pronounced dead on arrival. Statements given by Julieanne, Sean and the child’s grandparents claimed they’d noticed bruising on his body and that Sean had been seen to strike him. Like the other two babies, his body was testimony to an abusive life. He had a staggering 15 broken bones, which included numerous ribs, a broken spine and two broken collar bones, numerous bruises and partially collapsed lungs.
Dr Manock’s lack of expertise played a critical part in his misdiagnosis of bronchopneumonia for the death of each baby. The police officers had serious misgivings about these findings, and complained that Dr Manock’s diagnosis of death by ‘natural causes’ had torpedoed their investigations. No charges could be laid.
The anger and frustration that followed the post-mortems of the first two babies reached intolerable heights after Dr Manock’s third finding of death due to bronchopneumonia within less than two years. Something had to be done. The Coroner at the time was Wayne Chivell. He felt obliged to respond to the complaints of police and pediatricians, who were insisting ‘that the cause(s) of death may not have been correct and more seriously may have masked serious child abuse, even homicide’.8 Chivell decided to hold a single inquest into all three deaths. That inquiry got underway in late 1993.
The pathologist chosen to review Dr Manock’s autopsies was Tony Thomas. At that time he was Dr Thomas, later to become Professor. His qualifications were as extensive as Dr Manock’s were meagre. Dr Thomas had graduated from London University in 1973 and specialised in pathology and histopathology, training at St George’s Hospital Medical School. He immigrated to South Australia in 1986 and later became the Chief Examiner for the Royal College of Pathologists and the head of Anatomical Pathology at the Flinders Medical Centre.
Tony Thomas at the time was the Senior Specialist in Tissue Pathology at the IMVS. He was an expert in the field in which Dr Manock lacked any formal qualifications. He had performed thousands of autopsies himself and, though forensic pathology was not his primary function, he had plenty of experience preparing reports for and appearing before the courts.
Thomas found that Dr Manock had taken minimal tissue slides and organ samples. The information contained in these samples can be crucial in arriving at or eliminating possible causes of death. This is the real theatre of forensic pathology.
Another of Dr Manock’s shortcomings was the lack of detail in his reports. According to the eminent forensic pathologist Professor Derrick Pounder of Scotland’s University of Dundee, who worked in Adelaide in the 1980s, thorough documentation is an essential ingredient of any professional autopsy. He told me, during a 2003 Channel Seven Today Tonight interview, that:
The standard of documentation required is that the evidence is documented in a way which will allow an independent expert to arrive at a valid opinion and, if the defence experts felt that it was difficult for them to offer an opinion because there was inadequate documentation, then that’s a very serious criticism of the conduct of the original examination.9
Dr Manock’s forensic bible, the one he later relied on to support his findings on Anna-Jane Cheney’s death, appeared to be a slender pathologists’ primer, Lecture Notes on Forensic Medicine, produced by D. J. Gee of the University of Leeds. It was written as a simple rule-of-thumb guide to undergraduate medical students.
The Coroner’s Court has a discreet entrance off the busy central corridor of King William Street, occupying a corner of the old bluestone Magistrates Court building.
It was here on 11 February 1994 that Dr Tony Thomas delivered his 41-page report to Coroner Wayne Chivell. Although couched in professional and scientific language the criticisms of each autopsy were damning. Dr Thomas found little or no evidence of bronchopneumonia in any of the babies and nothing to justify a conclusion that this condition could have led to the deaths of any of the infants. Having received Dr Thomas’s findings the Coroner announced that a public inquest would be held, commencing in August 1994.
The inquest attracted considerable media interest. From the moment the evidence began to emerge it provoked headline after headline: ‘Forensic expert under fire’, ‘Homicide theory in baby deaths’, and ‘Baby death findings attacked again’.10 There was a feeling of hopeless inevitability in watching the witnesses come and go from the court. The grim-faced detectives, with their short haircuts and regulation moustaches, looked awkward in their tight grey suits. The infants’ parents played cat and mouse with the prowling TV media outside the court.
The testimony from the experts and the parents of the infants caused shock and outrage among those who attended: police, family members, child welfare workers, curious onlookers and of course the press.
Pediatrician Dr Burnell, who had found the swelling to Storm Deane’s brain, reported great difficulty in getting details of what had actually occurred from the baby’s father and mother. When Craig Deane was called to give evidence Dr Burnell remained in the court, and described being ‘totally transfixed by his account of teaching his baby, with no head control, to fall by throwing it onto a water bed … that is total child abuse. It might be unwitting, but it is child abuse.’11
The court’s attention was drawn to a strange mark on the baby’s bottom which resembled the scar left by a large cigarette burn. This, it was revealed, had been interpreted by Dr Manock as evidence of ‘nappy rash’. Deane, who gave himself the idiosyncratic title of ‘domestic engineer’, denied ever shaking his baby yet the evidence of Storm’s injuries contradicted his account. After his admission to hospital Storm’s shallow breathing, with the aid of a ventilator, was no more than the assisted mechanics of life. It was clear to the medical staff he was brain dead. When the ventilator was turned off, Craig Deane, in the presence of the attending Dr Matthews, twice placed his thumb across the baby’s throat. Deane explained ‘that he did not like to see the infant gasping. However, at Dr Matthews’ request he removed his thumb and the baby died peacefully.’12 The doctor was deeply disturbed by what he had witnessed.
William Barnard’s mother, Cherry Lee, told the inquest she had ‘snapped’ her baby’s arm on one morning when he’d awoken in a ‘bad mood’. She said, ‘I changed his nappy. I tried to comfort him but he wouldn’t settle down. I cracked! I snapped his arm. It’s a blur but I know I snapped his arm.’13 It was later put to the inquest by Alan Moss, counsel assisting the Coroner, that William’s death had to be treated as suspicious considering the death of his sister Cassie two years earlier being listed as SIDS. In his report Dr Thomas had said SIDS would have been a plausible diagnosis for William, except for ‘the presence of obvious non-accidental injuries, brain micro-hemorrhages consistent with severe shaking and the knowledge of a similar previous death within the family. I would seriously question whether the death was non-accidental.’14
When his turn came to give evidence Dr Manock claimed he had repeatedly asked police for information about the circumstances of William’s death but had received none. There was no record of any such requests and the police vigorously denied any such approaches had ever been made. The Coroner was damning, effectively disbelieving his evidence: ‘As I said in the matter of Barnard, I consider Dr Manock’s explanation that he was waiting for further information from police to be spurious.’15
The level of Joshua Nottle’s injuries was described as being of a magnitude only seen in adult victims of motor accidents. Dr Manock explained them as the result of poorly administered resuscitation techniques, yet they were critical long-term injuries. Joshua’s father, Sean McCluskey, was charged with murdering his son, but the charge had been reduced to ‘causing grievous bodily harm’ following Dr Manock’s findings of death by ‘natural causes’. That charge, too, was eventually dropped through lack of evidence. It was the same outcome for the other two infants. Aside from minor traces found in Joshua Nottle, there were no signs of bronchopneumonia in the lungs of each baby.
The Coroner held over the findings on the autopsies of these three tragic deaths until Henry Keogh was securely behind bars. While the oral evidence of the inquest had concluded in November 1994, and a further sitting took place in May 1995, it was not until 25 August – two days after Keogh’s conviction – that the findings were signed off and publicly disclosed.
The Advertiser journalist Sylvia Kriven, who covered the inquest, wrote a feature article entitled ‘Slipping through the gaps’.16 Kriven detailed the dreadful injuries those babies had suffered. She covered the distressing and bizarre evidence given by the parents and the degree of suspicion arising from their testimony. The article also reflected on the horror and dismay of the paediatricians, ambulance officers and police officers involved in all three cases. And of course Kriven quoted from the scathing findings of the Coroner once they were released. Yet Dr Manock was still described as ‘eminently qualified and … recruited from England in 1968 to pioneer South Australia’s first Forensic Science Centre’.17
‘Slipping through the gaps’ was a reference to the failure of the welfare system to intervene in time to save the lives of these three innocent infants. It should equally have been applied to Dr Manock, who’d been permitted to slip through the scientific gaps for three decades. He had also, just before Henry Keogh’s second trial in August 1995, been able to slip quietly into retirement.