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Your Refs: COR/01 & COR 792/00.                                    17.08.2006.                  
                                                                                             Patrick and Desley Collins,
                                                                                             Email: patdes@bigpond.net.au
 

Magistrate Mr Michael Halliday,
(as former Brisbane Coroner)
Petrie Magistrates’ Court.

Dear Mr Halliday,

The following list of our recommendations for changes to current toxicological and pathological procedures at QHPSS/QHSS and from expert witnesses from other institutions, was extracted from a submission that is herewith.

1. Queensland Health Scientific Services (QHSS) should employ a highly qualified post-mortem forensic toxicologist or, if such a scientist is currently employed by QHSS, the identity of this person should be make known to coroners and other persons with a legitimate interest.                                                                                  

   (Note)  Chemical analysts, eg Ms Hadley & Mr Bailey, have recently given erroneous evidence by going        beyond their area of expertise.  Examples are itemised in our submission.                                                                                                                                                      

2. (i): Probable post-mortem changes to blood drug concentrations should be reported in forensic interpretations but this does not, from our experience, happen in Queensland.

  (ii): Autopsy blood specimens should be taken as soon as possible after death, preferably at the death scene.

  (iii): Forensic experts should not make conclusions about the rapidity of a heroin/morphine death or the heroin/morphine route (oral or IV) from autopsy concentrations of FM and TM alone.

  (iv): The volume of autopsy blood specimens should be much smaller than those taken from Mitch Collins.

  (v): If CPR was administered post-mortem, this should be taken into account in expert opinions as it can elevate peripheral drug concentrations.

  (vi): Experts should advise the Courts that blood alcohol concentrations (BAC’s) can be higher at autopsy than at death as a result of post-mortem fermentation.  GHB can also be produced endogenously post-mortem.

  (vii): Experts should advise the Courts that autopsy drug concentrations can become  elevated during long storage periods if appropriate storage conditions were not adopted for the drug being considered.

3. The current system of internal investigations of QHSS staff by other QHSS staff  should be abandoned as these, from our experience, do not lead to constructive change.

4. Due and appropriate consideration should be given to review and/or re-open contentious post-mortem reports, inquests and trials to which Ms Lenore Hadley and Mr Neville Bailey contributed opinions or interpretations, if drugs were involved with the associated deaths.

5. A “Scientific Review Committee” for “handling complaints” about expert forensic science evidence should be established in Queensland.

6. Steps should be taken to eliminate a serious shortfall in relevant toxicological evidence from QHSS, as these promote legal doubts.

            (i): Bile: At autopsy, pathologists should record the volume of bile and  preserve a bile specimen for possible future analysis.

            (ii): When QHSS lacks the facilities to conduct pertinent tests on stored autopsy specimens, these should be contracted out to a laboratory that can.

7. Queensland Courts should abandon the practice of accepting the “opinions” of high  status scientists as being “factual” and also more valid than those of other scientists who are more in touch with current research.

8. The following replaces No 8 in our letter of 11.07.06

If doubt is introduced by an expert witness, pre-trial or pre-inquest meetings, by post-mortem forensic experts, should be adopted to eliminate scientific errors, and also needless but destructive adversarial evidence in Court.

9.  An ad hoc facility should be provided by QHPSS, eg at the John Tonge Centre, to provide next-of-kin, police and other interested parties with meaningful information about autopsies and interpretations of toxicological findings.

10. QHSS should report drug concentrations in a manner that is clear to involved lay persons: Eg instead of BAC = 24mg/100mL, this should be shown as 0.024%.  

11. A media liaison person should be attached to the Office of the DPP. In all cases when the DPP does not intend to proceed to trial, this person should be authorised to release to the media, in unequivocal terms, the reasons behind the DPP’s decision to drop the case.

12. Expert opinions should be based on "All aspects of the medicolegal death investigation triadi.e. toxicological, pathological, and environmental evidence from non-medical investigations, eg by police and coroners.

13. As an extension of “2” above, post-mortem scientific experts who provide written opinions about deaths should be asked to address the issue of possible post-mortem changes to blood drug concentrations. There is also a need for a system of monitoring or reviewing written reports from experts.

14.  Non-QHPSS experts should be prevented from making direct contacts with  QHSS analysts as this practice resulted in wrong drug concentrations being included in an Expert Opinion on Mitch Collins’ death.

15. Some storage conditions of autopsy specimens held by QHSS should be upgraded, if, as we suspect, they can result in post-mortem drug concentration changes.

Each of the above is dealt with in more detail in the attached submission, which is fully referenced and supported by attached documents where pertinent.

Thank you for your attentions,

Patrick J Collins and Desley K Collins  (parents of the late Mitchell Craig Collins).   


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Our Submission
(13 pages including references).

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