New Test Results 06-07
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Toxic Toxicology & QHFSS Response
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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,

We, the undersigned parents of the late Mitchell Craig Collins, who died on 16.12.00, provide the following summary of our recommendations for change: i.e. to the current system of collecting and evaluating post-mortem forensic toxicological and pathological evidence for Queensland Courts, especially by relevant experts in their opinions for inquests and pertinent trials.

Our recommendations include those made in our letters to you dated 11.07.06 [Ref 1A] and 19.07.06 [Ref 2], plus others that we did not mention in that correspondence. Copies of the letters are herewith, together with other documents and papers that are referred to in the text of individual recommendations below.

Recommendations 1-11 below are based on those in our letter of 11.07.06.

1. Queensland Health Scientific Services (QHSS) should employ a highly qualified post-mortem forensic toxicologist who, based on Goodman and Gilman’s authoritative pharmacological text (2001, p.67), would have expertise in “the medicolegal aspects of chemicals” and would be competent to “assist in post-mortem investigations to establish the cause or circumstances of death” [Ref 1B]. Such an expert would be competent to advise the Court on multiple aspects of drug concentrations that have, since at least 16.12.00, been determined, but erroneously interpreted, by forensic scientists (chemical analysts) from QHSS.

To interpret autopsy drug concentrations, a post-mortem forensic toxicologist should have expertise in pharmacokinetics (i.e. the absorption, metabolism, distribution and excretion of drugs in both the antemortem and post-mortem periods). To our knowledge, none was employed at QHSS when our son Mitch died, or subsequent to his death. This dearth resulted in forensic scientists, Ms Lenore Hadley and her “team leader (toxicology)” Mr Neville Bailey, who both lacked pharmacokinetic knowledge, giving erroneous advice to the Court and the Office of the State Coroner. It is possible, perhaps probable, that they also provided erroneous opinions to pathologists and police. Their most significant errors are listed below and also documented in attachments with Reference 1A. These include a notated transcript of Hadley’s Coronial evidence, pp.177-83 [Ref 1C (i)] and letters from Bailey dated 20.01.05, 28.06.05 & 1.12.05 [Ref’s 1D (i), (ii) & (iii)]. The last two contain admissions of errors by Bailey and Hadley. Also, pertinent tests were not conducted as these analysts and/or QHPSS pathologists possibly/probably did not know what tests were essential: see “6” below.

Ms Hadley’s evidentiary errors during Mitch Collins’ Inquest (20.08.01). The page numbers are from the official Transcript of Evidence, [Ref 1C (i)]:

(i): p.178: “morphine … It’s metabolised in the gallbladder”. Note: This is incorrect. Morphine is metabolised primarily in the liver: not in the gallbladder.
(ii): p.178: [from the gallbladder] “through the bile it goes back into the stomach.” Note: This is incorrect. The bile empties into the duodenum below the stomach. Versions of this error were repeated on p’s 180 (twice), 181 (twice), & 182 (twice).
(iii) & (iv): p.181: Re her sources and the percentage of morphine that supposedly enters the stomach she stated: “The literature indicates it’s roughly 20 percent but it will vary with individuals and their own metabolism system.” Note: There is no “literature” that supports this mistaken notion of 20 percent to the stomach. Both of these errors were repeated on p.182.
(iv): p.182: She erroneously confirmed to Mr Kissick (barrister) that she had analysed Mitch’s bile.
(v): p.183: “[a] nanogram is 1,000th of a milligram.” This is wrong. A nanogram is 1,000,000th of a mg (or 1,000,000,000th of a gm) [Ref 1C (ii). This error caused confusion about how to interpret tabled science papers.

Note: We first reported the above to QHSS in May 2002 but it was not investigated [Refs 4A & 4B] until we reported it again in 2005 (to the State Coroner): i.e. after Mr Bailey repeated the central error re bile (see below). 

In addition to the above:

(i): On p.179, Ms Hadley admitted that she did not scientifically confirm if a blood-like liquid in Mitch’s stomach was blood, although Mr Halliday had apparently asked for an analysis of Mitch’s stomach contents. This lack of certainty was significant as Professor Drummer, in an opinion for the DPP on 20.08.04, hypothesised that morphine could have entered Mitch’s stomach via blood that was present in that organ [Ref 7].
(ii): On p.179 Ms Hadley indicated that Mitch’s specimens were analysed after “a short period of time” and therefore no drug concentration changes would have occurred during storage. In reality, Mitch’s unfrozen blood specimens were analysed on 15.02.01 after two months’ storage.
Also, his frozen gastric contents were analysed on 4.08.01 after 7.5months’ storage. In both instances, there is reason to suspect that concentrations could have changed. This is discussed in Recommendation 15.
(iii): Professor Drummer, in paragraph 17 of his opinion dated 20.08.04 [Ref 7], included two incorrect drug concentrations, which he stated were provided by Ms Hadley. This is discussed in Recommendation 14 (below).

Mr Bailey’s gratuitous but erroneous statement re bile flow: In a letter to Ms Hervey from the Office of the State Coroner (20.01.05), in response to our requests for data, Mr Bailey gratuitously included the following comment, presumably to support Ms Hadley [Ref 1D (i)]. He stated:

            “Morphine is metabolised within the liver to morphine glucuronide, some of which is then emptied into the stomach. Within the stomach, morphine glucuronide can undergo hydrolysis to morphine and the absorption cycle of morphine from the stomach continues.”

In reality, as stated above re Hadley’s evidence, bile does not empty into the stomach but into the duodenum below the stomach.

Perhaps partially influenced by submissions that we made about the above to Attorneys General (The Hon Mr Welford and The Hon Mrs Lavarch), on 7.10.05 Mr Peter Forster recommended to the Minister for Health (The Hon Mr Robertson), the removal of the Director of QHSS and also the manager of Forensic Services [Ref 3A, pp.1-2, attached]. We believe these persons were, respectively, Professor Michael Moore an environmental toxicologist [Ref 3B] and Ms Robyn Kelly. When these recommendations are considered in conjunction with the scientific ignorance of Ms Hadley and Mr Bailey above, many post-mortem forensic scientific opinions that have been provided by QHSS experts must be suspect.

Note: We do not know what influence our submissions had on the Ministerial Task Force, which involved Mr Forster and which investigated QHSS in 2005. This was because Attorney General Lavarch, who took over from Mr Welford, did not inform us of the outcomes of our submissions, which Mr Welford had passed to the Task Force (see attached letters from both [Refs 3C & 3D]).

2.  (i) Probable post-mortem changes to blood drug concentrations should be reported in forensic interpretations [Ref 5A, p.53] but this does not, based on our experience, happen in Queensland. In Mitch’s instance, at least five paid experts ignored this phenomenon known as post-mortem redistribution (PMR) in their evidence or opinions (see below).

   (ii): Autopsy blood specimens should be taken as soon as possible after death, preferably at the death scene. If specimens are not taken immediately after death, autopsy concentrations of numerous drugs can be higher than they were at the moment of death [Ref 5A, p.48]. This should be taken into account in expert opinions. For instance, a high blood drug concentration could be incorrectly interpreted as either (a) evidence of high tolerance for that drug or (b) evidence of a very rapid death from that drug. However, no expert considered this issue in relation to Mitch, although his autopsy specimens were taken approximately 47hrs post-mortem.

Note: Although Gerostamoulos and Professor Drummer published in 2000 that no statistically significant post-mortem changes to Morphine (FM) concentrations occur, their specimens were taken from 21 bodies at admission to the mortuary and again at autopsy [Ref 5H]. I.e. their data did not include concentrations at death or soon after. In the face of their statistics, the FM level increased by 850% in their Case No 15 and by 433% in Case No 16. Also, a study of their results, by Patrick Collins, showed only a low correlation (r = 0.5 & r2 = 0.25) between the admission and autopsy concentrations. In other words, admission concentrations cannot validly be predicted from autopsy concentrations [less than 25% better than chance]. It is even less valid to predict death concentrations from autopsy data [Ref 5I].    

  (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. The major morphine metabolites are morphine glucuronides (MG). The MG concentration is calculated from TM minus FM. Drummer effectively concluded that Mitch died quickly from an IV injection as his autopsy MG to FM ratio was 2:3 = 0.67. He rejected oral consumption as, in living persons, the MG:FM ratio is normally much greater than 1.00. However data from Gerostamoulos and Drummer’s paper in (ii) above [Ref 5H] showed that the MG:FM ratios in 3 instances decreased between admission and autopsy as follow: In No 15 from 2.00 to 0.67; in No 16 from 1.72 to 0.54; in No 20 from 2.1 to 0.66. In other words, the admission ratios were consistent with oral consumption but the autopsy ratios were consistent with rapid IV deaths. Also, as Drummer’s data did not include concentrations at death, other similar changes might have occurred prior to autopsy. The correlation study mentioned above [Ref 5I] also shows that ratios at death cannot be validly predicted from autopsy ratios.     

  (iv): The volume of autopsy blood specimens should be much less than for those taken from Mitch Collins. Crandall et al (2006), who used 3mL blood specimens for their research, reported that specimens of 10mL or more, even if taken from a femoral vein, could be contaminated by blood with higher morphine concentrations: eg from the heart [Ref 5G]. These authors showed that on average, in autopsy blood, left ventricular total morphine (TM) concentrations were twice as high as in femoral blood, but the range was (0.6 – 6.9) times. However, a similar range (1.0 – 5.8) had been recorded in 1995 by Dalpe-Scott et al [Ref 5D]. Crandall’s conclusion suggests that Mitch’s autopsy peripheral blood specimens could have been contaminated in this way, as three 10mL specimens were taken from his body [Ref 5J]. Presumably this happens with many decedents at QHPSS. However, post-mortem CPR attempts should also be taken into account (see below).

  (v): If CPR was administered post-mortem, this should be taken into account in expert opinions as it can elevate peripheral drug concentrations [Ref 5B, pp.6-7]. This is caused by central blood with high drug concentrations being pumped to the peripheral areas such as femoral blood, which is analysed after autopsy. However, no expert mentioned this in relation to Mitch, to whom two sessions of post-mortem CPR were administered: i.e. by a neighbour and by paramedics, approximately two hours after he died.

  (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 [promoted by bacteria, yeast or fungi], if the body has lain in a high temperature environment or if the skin has been damaged by injury [Ref 5C (i)]. Mitch’s body lay in a non-airconditioned room in Brisbane on a hot mid-summer’s day approx 280C [Ref 5C (ii)] for approximately 6hrs prior to transportation to the mortuary. His blood specimens were not taken and preserved until 47hrs post-mortem. It was therefore possible that his low BAC of 0.024% could have been even lower at death. However, no expert mentioned this in his/her evidence or opinion.

Note re GHB: Some recent studies have also shown that the date rape drug GHB can be produced spontaneously (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. However, no expert discussed this in relation to Mitch’s specimens, some of which were not analysed until after 7 months storage. Others were stored for 3.5 years prior to analysis. For a referenced discussion of this see No 15 below.

Comment: No paid post-mortem forensic science expert mentioned that Mitch’s autopsy blood concentrations of 6MAM, free morphine (FM), total morphine (TM), Codeine, Methamphetamine, MDMA and alcohol (ethanol) had probably increased between death and autopsy in his peripheral blood specimens that were analysed. The relevant experts were Dr Terry Sinton, Ms Lenore Hadley and Mr Neville Bailey (all from QHPSS), Dr Patrick Carroll (Redcliffe Hospital), Professor Olaf Drummer (Victoria), and Assoc Prof Johan Duflou (NSW). That the blood concentrations of the above and more than a hundred other drugs can change post-mortem has been well documented: eg by Dalpe-Scott et al (1995) and/or by Leiken et al (2003) [Refs 5D & 5A].

As a result of the above dearth, the relevant opinions of all of the above paid experts were flawed: i.e. because they erroneously based their interpretations on Mitch’s autopsy blood concentrations as if these were present at the moment of death.

Because of his influential status in Australian toxicological circles and in Australian Courts, the above is particularly pertinent to Professor Drummer’s opinions about Mitch’s survival time, and also the possibility of two heroin injections. As shown in (ii) & (iii) above, neither of these conclusions took into account possible post-mortem changes to Mitch’s blood FM, TM & MG concentrations. Drummer also ignored probable post-mortem changes to Mitch’s methamphetamine, MDMA, codeine, alcohol and Venlafaxine blood concentrations. In his 2001 textbook, he referred to post-mortem changes to blood concentrations of methamphetamine [Ref 5E p.’s 40 & 42] and MDMA (Ref 5E p.’s 91 & 374).  However, in relation to morphine (FM) he stated (p.40 & p.251) that it appears to show little or no post-mortem redistribution (i.e. concentration changes) in blood. Drummer has though published that blood concentrations of FM (and therefore TM also) can increase if un-metabolised heroin and 6-MAM convert to morphine post-mortem [Ref 5 F].

Note: As Drummer’s influence is so significant, his rejection of the post-mortem redistribution (PMR) of FM, and the need for a system of validating evidence from experts such as he, is discussed further in No 13 below.

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. In correspondence dated 21.05.02 to Ms M Daly (a QHPSS senior counsellor), which she passed to Professor Moore (QHPSS) [Ref 4A], we drew attention to the above mentioned errors in Ms Hadley’s Coronial evidence. However, Professor Moore took no action other than to advise us on 13.06.02 that he and his staff could not discuss the issues we raised, as they were “still before the court” [Ref 4B]. When we documented Ms Hadley’s errors, and another by Mr Bailey, to the State Coroner three years later, he did seek explanations. However, Mr Bailey conducted the investigations into himself and Hadley. As shown in Ref 1D (iii) above, on 1.12.05 Mr Bailey confirmed some of the errors we reported about Ms Hadley, but he ignored others. Similarly, Professors Drummer and Duflou failed to report Hadley’s flawed Coronial evidence although they had been provided with transcripts of her evidence [Ref’s 2B & 2C].

Our recommendation re alternatives to internal investigations are in No 5.

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. From evidence cited in No 1 above, it is unequivocal that these QHSS chemical analysts have provided evidence or opinions that were erroneous and beyond their areas of expertise, in relation to our son’s death [Refs 1C (i), 1D(i), 1D(ii) & 1D (iii)]. It is therefore possible/likely that they have done so in relation to other deaths. Accordingly, the Office of the State Coroner and the Office of the DPP, should be asked to identify relevant contentious post-mortem reports, inquests or trials, if any exist. These could then be dealt with by suitably qualified and objective non-QHSS experts, eg as recommended in No 5 below.  

5.  A “Scientific Review Committee” for “handling complaints” about expert forensic science evidence should be established in Queensland. As there is no doubt that flawed forensic science evidence is being presented in, and for Queensland Courts (see No’s 1 & 2 above), it is essential that a system of at arm’s length monitoring of such evidence be introduced. This would over-ride or replace current “protective” internal investigations (see No 3 above). Viable models were reviewed in Chapter 7 of the House of Commons Science and Technology Committee’s Seventh Report of Session 2004-05: Forensic Science on Trial [Ref 4C: i.e. Chap 7]. This provided a model for reviewing past trials and inquests as mentioned in No 4 above. As the whole of this chapter is relevant to the Queensland problems, a complete copy is herewith. However, we draw particular attention to paragraph No’s: 130, 142, 151-52, 163, 170, 173, 175 & 176. Paragraph 130, p.60, is highly relevant. However, the most pertinent recommendations are in paragraphs 173, p.76, and 176, pp. 77-8. The latter discusses the need for a “Scientific Review Committee”.  

6.  Steps should be taken to eliminate a serious shortfall in relevant toxicological evidence from QHSS, as these promote legal doubts. From our experience, deficits in such evidence are a likely consequence of pharmacokinetic ignorance on the part of QHSS scientists and possibly some pathologists. The adoption of the following procedures would eliminate deficits identified by us and others who gave opinions about Mitch’s death.: 

(i): Bile: At autopsy, pathologists should record the volume of bile and preserve a bile specimen for possible future analysis. Although this does not happen in Queensland, it does in NSW and Victoria. It was also recommended by Vanbinst et al (2002, p.35) [Ref 6A], as bile drug concentrations can be much higher than in blood. Also, drugs are sometimes found in bile when none is detected in blood. In Mitch’s instance, because the above procedures were not adopted, serious doubts were raised by Dr Carroll, Professor Drummer and Professor Duflou about the DPP’s case for the oral consumption of heroin. It was, for instance, suggested that Mitch’s high gastric FM and TM concentrations, when compared with those in his blood, could have derived from bile that had entered his stomach from his duodenum. However, as the quantity of bile that remained in his gallbladder was not recorded at autopsy, and because no bile specimen was preserved, these hypotheses could not be confirmed or negated. Instead, these evidentiary deficits contributed to the DPP’s decision to enter a nul prosequi.

(ii): When QHSS lacks the facilities to conduct pertinent tests on stored autopsy specimens, these should be contracted out to a laboratory that can. In Mitch’s instance, in addition to the bile origin hypothesis in (i) above, Professor Drummer also hypothesised that blood from a gastric haemorrhage, shortly after heroin entered Mitch’s body, might have been the source of his high gastric FM and TM concentrations. This and the bile source hypothesis could possibly have been confirmed or negated, if the quantities of gastric bile and gastric blood (if any) had been ascertained. However, Ms Hadley advised us via the State Coroner’s Office that QHSS cannot conduct either of the relevant tests [Ref 6B], although a scientist from Sullivan Nicolaides told us that such tests are available at some laboratories. We therefore do not understand why QHSS did not out-source these tests, especially so considering that the former Brisbane Coroner, Mr Michael Halliday, had asked QHSS to analyse Mitch’s stomach contents. Instead, the corresponding lack of evidence contributed to the DPP’s nul prosequi decision.

From Ms Hadley’s and Mr Bailey’s admissions of pharmacokinetic ignorance in No 1 above, it is certain that neither knew what tests should have been conducted to determine oral consumption or intravenous injection of heroin. Vital tests were therefore not conducted and every expert opinion about Mitch’s death was based on insufficient data to make unequivocal conclusions. Associated doubts made it impossible for the ODPP to proceed with a trial based on the notion of “beyond reasonable doubt”. As this possibly occurs frequently without detection, we believe Queensland Coroners and Prosecutors should emphasise environmental evidence, rather than toxicological evidence, when forming conclusions about deaths or conducting trials. Also, when expert opinions such as Professor Drummer’s, that include significant hypotheses as a result of evidence not collected by QHSS, associated conclusions should not be relied on by Qld Coroners and Prosecutors. This is supported by Professor Duflou’s opinion, in which he stated that from the available evidence, he could not decide if the heroin route was oral or IV [Ref 11 & Ref 8].

From our examination of the doubts raised by Dr Carroll, Professor Drummer and Professor Duflou, the following data/tests, in addition to those in his post-mortem report, should also have been ascertained for Mitch:

            (i): The volume of bile in his gallbladder.
            (ii): The bile FM and TM concentrations.
            (iii): The proportion of bile (if any) in his stomach.
            (iv): The proportion of blood (if any) in his stomach.
            (v): The concentration of the 6-MAM that was “detected” in his stomach.
            (vi): Heroin/morphine concentrations, if any, in tissues damaged by syringes.
            (vii): The presence of an oral narcotic such as GHB or Rohypnol in gastric, blood and urine specimens.

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. It is apparent that Queensland Courts accept the evidence of high status experts as being more accurate than opinions from experts with less status. As was illustrated in paragraphs 130 & 142 of Chapter 7, in the above House of Commons report [Ref 4C], this is illogical and legally dubious. Eg. in the instance of Professor Drummer [Ref 7], he apparently based his most pertinent opinions on heroin research from a dissertation by Gerostamoulos, that he approved in early 1997. However, recent papers, [eg Ref’s 5A & 5G], do not support the conclusions from and/or the methodology adopted in this doctorate. For such reasons, every expert who provides a relevant opinion should, if requested, provide a review of the most recent relevant publications. If this is not provided the opinion should be rejected.

8.  The following replaces No 8 in our letter of 11.07.06 [i.e. in Ref 1A].

Pre-trial or pre-inquest meetings, by post-mortem forensic experts, should be adopted to eliminate scientific errors and needless but destructive adversarial evidence in Court. Such meetings could save thousands of dollars, needless stress, and shorten the legal process by years in some instances.

Nearly six years will have passed between Mitch’s death and until Magistrate Halliday hands down his final conclusions on 1.09.06. A great deal of this time delay was brought about by a lack of certainty amongst forensic experts. However, there is still a lack of agreement amongst those experts. Related issues were reported on by the above House of Commons Committee, who recommended the adoption of pre-trial meetings by forensic experts [Ref 4C, paragraphs 151 & 152]. While it might not be possible to arrange these in some circumstances, we believe the benefits would justify calling them whenever significant doubt has arisen. In Mitch’s instance, doubt was introduced in the mind of Principal Crown Prosecutor Byrne by Dr Patrick Carroll in early 2002.

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. This should be available even if the involved pathologist or toxicologist could be called as a witness at an inquest or trial, for an alternative, non-involved expert could answer most queries.

Immediately after we mentioned to Dr Sinton, when he completed Mitch’s autopsy, that we were considering requesting an inquest, he refused to discuss aspects of Mitch’s death with us. He did so as he expected to be called as a witness, if an inquest were to be granted. We accepted this. However, we were denied access to any qualified QHPSS forensic expert although we had numerous unanswered queries, including a desire for a meaningful interpretation of the toxicological test results. A senior counsellor attempted to address some of these matters by relaying answers after talking with an unidentified expert. However, as these answers were far from sufficient for our needs, our only alternative was to seek interpretations from non-QHPSS experts: i.e. Dr Charles Appleton and Dr Patrick Carroll. Both were extremely helpful, although detective Mal Gundry erroneously suggested that we had misrepresented Dr Appleton’s evidence to the Brisbane Coroner. In the instance of Dr Carroll, he charged us $2,400.00 (@ $400.00/hr) but he withdrew as an inquest witness when he could not explain data in a paper tabled by Ms Hadley.

We were also disappointed when we learned that someone at QHSS had apparently provided investigating detectives with a sub-standard interpretation of Mitch’s toxicological results. For instance, they told us that Mitch’s blood FM level of 0.3mg/kg was relatively low in the fatal range and that he had therefore died from an MDMA overdose. However, FM = 0.3mg/kg was, but unknown to us, higher than the median fatal level of 0.25mg/kg that Professor Drummer later reported in his expert opinion [Ref 7, paragraph 26].

Our point is: if QHPSS were to establish an ad hoc service as recommended above, it would save time and money for all concerned. More importantly, it could ensure that police and next-of-kin could make enlightened decisions: eg about investigations, requests for inquests and providing answers to family members and the deceased person’s friends. Emotional benefits to grieving loved ones are presumably obvious.  

10.  QHSS should report drug concentrations in a manner that is clear to involved lay persons. Dutton Park CIB detectives misinterpreted Mitch’s BAC (blood alcohol concentration) as BAC = 0.24%, because it was reported by QHSS as 24mg/100mL. In reality his BAC = 0.024%, but the detectives (and Mr Fairclough for Mardi McLean), until August 2001, continued to believe Mitch was very drunk on the day he died. As this no doubt influenced the police conclusions in relation to Mitch’s assumed irresponsibility, QHSS should report all drug concentrations in a manner that is readily understood by police, lawyers and other lay persons. [Ref 9].

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. This would ensure that the media does not publish erroneous data such as stating that the previously charged person was “not guilty”.

In the instance of Mardi McLean, who had been charged with Mitch’s murder, the DPP entered a nul prosequi based on Professor Drummer’s opinion re IV. Accordingly, the Courier-Mail reported that McLean was innocent [Ref 10]. However, Principal Crown Prosecutor Michael Byrne told us that he still believed that McLean was involved with Mitch’s death. The case was in fact dropped because Drummer had introduced potential “reasonable doubt”: i.e. if jury members were to be presented with his findings. Unfortunately, this was not known by the Courier-Mail and Mitch’s reputation was publicly denigrated. Accordingly, it should be mandatory for prosecutors to provide the media with a detailed report of such decisions. We also believe that in some instances, the State Coroner could also issue relevant media releases.

Recommendations 12 & 13 below are based on our letter of 19.07.06 [Ref 2].

12.  The Queensland Office of the DPP and also the Office of the State Coroner, when engaging a post-mortem forensic science expert to provide an opinion on a death, should stipulate that the expert consider "All aspects of the medicolegal death investigation triad” i.e. toxicological, pathological, and environmental evidence from non-medical investigations, eg by police and coroners [Ref 2A]. If an inquest had been held, the expert should be provided with, and be asked to address, all relevant Coronial evidence, including non-medical evidence, from inquest examinations (not just police statements).

In spite of the above recommendation, a version of which appeared in the British Medical Journal, neither Professor Drummer (who co-authored the relevant article) [Ref 2A], nor Professor Duflou, was provided with non-medical evidence acquired during examinations of witnesses during Mitch’s Inquest [Refs 2B & 2C]. This included McLean’s claim that she had seen a large lump on Mitch’s arm, allegedly from a needle that missed a vein. However, Duflou, in his opinion, stated that needle marks might not be seen for several reasons, none of which addressed the above [Ref 11, paragraph 8]. In other words, if the above needle damage had been on Mitch’s arm at around 9.30am, the paramedics should have found associated damage when they searched for needle access marks at around 12.45pm. Unfortunately, as Duflou did not read this evidence, his opinion was seriously flawed in this regard, as was Drummer’s [Ref 7]. It is pertinent that the late Professor Herdson was adamant that needle marks become more obvious with time [Ref 12]. Unaccountably, however, the ODPP did not ask Duflou and Drummer to comment on McLean’s evidence from her Coronial examination, and neither apparently sought the relevant transcripts.

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.

We included Professor Drummer and Professor Duflou in our list of paid experts who did not address possible post-mortem changes to blood drugs. However, as the DPP entered a nul prosequi decision, neither Drummer nor Duflou was subjected to an examination or a cross-examination of his report. However, both reports are now included amongst documents in the public record of Mitch’s death. Accordingly, we believe that an objective system of reviewing such opinions should be established. As was documented in the House of Commons Report above, the Courts should not assume that even highly regarded experts do not form invalid conclusions. We also believe that if a review committee existed, it should establish minimum criteria that should be met by experts in their written opinions. That written expert opinions can contain even factual errors is well illustrated in an attached letter from us to State Coroner Barnes [Ref 13]. See also [Ref 8], which includes pertinent correspondence from Professor Duflou.

Additional recommendations:

14.  Non-QHPSS experts should be prevented from making direct contacts with QHSS analysts. Eg Professor Drummer reported three incorrect drug concentrations in his expert opinion of 20.08.04. He stated that he acquired these during telephone conversations with Ms Hadley from QHSS. Associated “evidentiary problems” resulted in the ODPP engaging Professor Duflou to provide an alternative opinion dated 21.03.06. This needlessly delayed the DPP’s investigation by 1 year and 7 months, which could have been avoided if Drummer had sought the relevant data on formal drug certificates from the State Coroner [Ref 13] and [Ref 7 paragraph 17].

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

(i) Blood: Mitch’s analysed blood specimens were refrigerated at 40C after being placed in tubes that contained 1% sodium fluoride preservative and anticoagulant potassium oxalate. The pH was not recorded and no pH buffer was added. [Correspondence from Mr N. Bailey, team leader (toxicology) at QHSS, 23.03.05 & 1.06.05].

Skopp et al (2001, p.6) reported that bacteria from the gastrointestinal tract can be present in post-mortem blood samples as soon as 5 hours after death. These authors also investigated post-mortem hydrolysis of morphine glucuronides (MG) to FM in post-mortem blood. They concluded, “total inhibition of drug degradation can only be achieved if these specimens are stored at –200C. That means that drug concentrations in post-mortem blood can be preserved at the moment of collection only”.

Based on the above, it appears that post-mortem changes to some drugs must occur during storage at QHSS, especially if analysis of specimens is delayed.

(ii) & (iii) Gastric Contents & Liver Specimens: Mitch’s gastric (and liver) specimens were frozen: “temperature range minimum of –50 C on defrost cycle with normal operating range –150C to –180C.” The pH was not determined and no pH buffer or preservative was added [Correspondence from Mr N. Bailey, team leader (toxicology) at QHSS, 23.03.05].

Based on the Skopp et al (2001) study above, it would appear likely that post-mortem changes to drugs in gastric contents and liver specimens are likely to change during storage as no preservative is added at QHSS, especially so if the storage period is lengthy. In Mitch’s instance, his gastric contents were not analysed until 7.5 months after he died. Not surprisingly, Professor Drummer suggested that some of Mitch’s gastric MG could have hydrolysed to FM during storage [Ref 7].

We trust that the above summary of our recommendations for change are constructive. Thank you for your attentions.

Best wishes;

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

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