Your Refs: COR/01 & COR
Patrick and Desley Collins,
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
(Note) Chemical analysts, eg Ms Hadley
& Mr Bailey, have recently given erroneous evidence by going
beyond their area of expertise. Examples are itemised in
2. (i): Probable post-mortem changes to
blood drug concentrations should be reported in forensic
interpretations but this does not, from our experience, happen
(ii): Autopsy blood specimens should be
taken as soon as possible after death, preferably at the death
(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.
volume of autopsy blood specimens should be much smaller than
those taken from Mitch Collins.
CPR was administered post-mortem, this should be taken into
account in expert opinions as it can elevate peripheral drug
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
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
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
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
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
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 triad”
i.e. toxicological, pathological, and environmental
evidence from non-medical investigations, eg by police and
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
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.
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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