The Baby Deaths chain reaction

Andrew L. Urban.

They have come to be known as The Baby Deaths. Three unrelated babies who died between October 1992 and August 1993 in Adelaide, were each victims of physical abuse but the State’s Chief Pathologist (1968 – 1995), the insufficiently qualified Dr Colin Manock, reported the cause of death in each case as natural: bronchopneumonia. It was the start of a 20 year chain reaction that began with a wrongful conviction which should have never happened.

Storm Don Ernie Dean was three months old when he died, on Friday, October 16, 1992, at the Adelaide Children’s Hospital. The cause of death was given by Dr Colin Manock as bronchopneumonia, a basic lung infection. The police and the doctors involved thought the suggested causes of death given by Dr Manock were incorrect, and may have concealed serious child abuse, or even homicide. They made their views known to the Coroner.

In his book, A State of Injustice, Dr Bob Moles compiled the following reports (republished here with permission), based on the Coroner’s findings, the transcript of evidence before the Coroner, the report of Dr Tony Thomas that was accepted by the Coroner, Dr Manock’s autopsy reports in each of the three deaths, and the ABC TV 4 Corners program, ‘Expert Witness’.

squeezed the baby around the chest

 Storm was born on 18 July 1992 to Craig and Heather. He lived with his parents and three siblings who were aged ten, six and four. Craig stayed at home to look after the children, and Heather worked as a telemarketer. Craig said that on Thursday 15 October 1992, while he and Heather were at home, he took Storm from the baby bouncer by grabbing hold of the front of his jumpsuit without supporting his head. Craig described taking him to the master bedroom: ‘I picked him up by the scruff of his clothes and carried him like a little carrying bag … I flipped him, and he went about two feet forward and then landed on the bed.’

 Craig told the doctors at the time that he had flipped all his children in this manner, throwing them through the air onto the bed. He had the belief that this taught the babies how to fall properly and would be helpful during their later life. In an effort to show them how to breathe from the diaphragm rather than from the chest, he had squeezed the baby around the chest on various occasions.

After putting Storm on the bed, he and Heather went outside to fix his Harley Davidson motor bike. Heather later went to check on Storm and found him looking pale and not moving. Craig tried mouth-to-mouth resuscitation, but without success. Heather called an ambulance.

When the ambulance arrived, Craig was said to have run out of the house with the baby and to have fallen over. However Storm didn’t hit the ground. The ambulance officers connected Storm to an electrocardiograph to measure his heart activity. They said that he was cold and grey, he had no heartbeat and he wasn’t breathing. He was rushed to the Lyell McEwin hospital and then from there to the Adelaide Children’s Hospital. The following morning it was agreed that Storm’s life support would be terminated and Storm was pronounced dead.

William (Billy) Barnard, aged 9 months, died on 31 July 1993, at the Adelaide Children’s Hospital. Dr Manock conducted the autopsy. His diagnosis was that Billy, too, had died of bronchopneumonia. He also had some fractures of the arm. A detective from the CIB said that because he was told that the cause of death was bronchopneumonia, it meant that he couldn’t undertake further inquiries.

bruises and fractures

Billy was born on 29 October 1992 to Cherry and David. He lived with his parents and an older sister aged three years. Another sister had died when she had been only three weeks old. On the evening of Thursday 30 July 1993, Cherry was in a sleeping-bag with Billy. The following morning, she said, she found him not breathing. She called for an ambulance and the baby was taken to the Adelaide Children’s Hospital. Billy was pronounced dead shortly after arrival.

 One ambulance officer said he had remembered attending at that address before when the other child had died. The ambulance officers noted that Cherry seemed ‘detached’, ‘nonchalant’, ‘unconcerned’ – much the same as on the first occasion. The ambulance officer conveyed his misgivings to the medical authorities on arrival at the hospital.  

The physical examination of Billy by Dr Donald (the director of Child Protection Services) revealed injuries such as bruises and fractures, that were possibly non-accidental, as well as scars which were unusual in a child that young. The body was sent to the Forensic Science Centre for an autopsy.

Cherry, when talking about Billy, admitted to having ‘cracked and snapped his arm’. Billy’s sister had also died while sleeping with her mother in a sleeping-bag. The Coroner said that David was more articulate and careful in his answers to questions than Cherry was. The Department of Family and Community Services had had extensive involvement with the family, and there was evidence of neglect and poor parenting skills. Cherry had had a disturbed childhood, as had David, who had served a sentence for assaulting a child in an earlier relationship. The Coroner said that the Family and Community Services plan was clearly insufficient.

 Joshua Clive Nottle, aged 9 months, died on 17 August 1993, at the Modbury Hospital, Adelaide. Dr Manock conducted the autopsy. Yet again, the cause of death was described as bronchopneumonia, this time associated with multiple rib fractures.

Bruising and rib fractures

Joshua was born on 27 November 1992 to Julieanne and Sean. He had a brother who was about two years old. On Tuesday morning, 17 August 1993, Joshua was found dead in his cot. He was taken to Modbury Hospital where he was declared dead. Bruising and rib fractures were noted. Two detectives from the CIB attended. After an interview, Sean was arrested and charged with Joshua’s murder. When the results of the autopsy were known, this was then reduced to intentionally causing grievous bodily harm. 

Joshua’s body was transferred to the Forensic Science Centre where Dr Manock conducted an autopsy the same day. Again, there was no other doctor present during the examination, however the CIB officers were present. Bruising was found in addition to a spine fracture and rib fractures. Yet again, the death was described as bronchopneumonia, this time associated with multiple rib fractures. 

 Knowing that there was evidence of spinal injury and multiple rib injuries, the detective investigating the case spoke to Dr Manock about his concerns. He said that Dr Manock explained to him that throwing the child into the air and catching him could have caused the rib injuries. Dr Manock also said that the spinal injury might have resulted from ‘vigorous attempts at resuscitation’ by the father. Dr Thomas took the view that this was not correct.

As the Coroner said: 
“Dr Manock’s evidence here reflects his apparent attitude that this is an issue of credibility, that it is his word against that of Dr Thomas rather than an issue of scientific and professional method. Had Dr Manock done as Dr Thomas suggested he should have, this would not, and should not, have been an issue at all.” 

multiple fractures … birth injuries?

The Coroner, Mr Wayne Chivell, had commissioned histology specialist Dr Tony Thomas to report on all three as part of the inquest held 1994-95. (Dr Thomas was Associate Professor in anatomical pathology at the Flinders Medical Centre in Adelaide and had had forensic pathology experience in the UK and New Zealand as well as Australia.)

One of the babies had multiple fractures which were put down as birth injuries.

Dr Thomas knew that they could not have been birth injuries, “you could get some handle on that from X rays and the formation of new bone so that the radiologists at the women’s and children’s hospitals who looked at him and said this can’t be birth injuries. And I remember one of the babies was described as having nappy rash and that was a discrete ulcer on the buttock or just above the buttocks, which looked like a burn really. So that was not nappy rash. So it was these sorts of injuries that didn’t really fit in with what Dr Manock had said and how he interpreted them. And then came the histology …”

The histology gave Dr Thomas a completely different result to that which Dr Manock had put down.

During the inquest into the death of Billy Barnard, Dr Manock said he could not recall why he did not weigh the lungs. He agreed that bronchopneumonia was unlikely to have been the cause of death. He was unable to recall what he saw in the slides which had led him to this conclusion. The Coroner said that it was astonishing that a pathologist in his position had not seen fit to write it down. Dr Manock said he did not send the brain for examination, because he was waiting for something from the detectives, so that he could tell the specialist what to look for. The Coroner said that he was perplexed at this statement, as the specialist was perfectly capable of examining the brain without being told what to look for.

The Coroner concluded that, of the three deaths, that of Joshua Nottle was the most serious, with non-accidental injuries most evident. He said that Dr Manock’s diagnosis prevented the establishment of a causative link between the non-accidental injuries and the death. In the Coroner’s view, what should have been a homicide investigation became one only of serious assault.

In his conclusions, the Coroner stated that Dr Manock’s autopsies in these three cases had achieved “the opposite of their intended purpose”. They had closed off inquiries rather than opening them up. Once the deaths were diagnosed as resulting from natural causes, the police were unable to follow up on their investigations. (Ironically, the Coroner’s own action of withholding his findings also had the opposite effect of its intended purpose.)

The Coroner noted that Dr Manock had said that he had seen things which could not have been seen.

The Coroner said that some of Dr Manock’s answers to his questions had been “spurious” (not genuine).

But then a devastating chain reaction was set off by the Coroner’s inexplicable decision. The Coroner, Mr Chivell, had finished writing his Findings a few days before the trial of Henry Keogh began, but he decided not to release his Findings, which discredited Dr Manock as an expert witness. According to the November 7, 1996 affidavit of Michael Sykes, solicitor for Keogh, “The Coroner said he was sensitive to the fact that Mr Keogh’s trial was proceeding at the time he was ready to publish his Findings. He knew that Dr Manock was a principal Crown witness. So as to avoid a mistrial he decided, of his own volition, to delay publishing the Findings until after the trial had concluded.”

It is astonishing that the Coroner recognised that his Findings would impact on the trial, but failed to see that such an impact was highly desirable in the interests of justice.

Had the Coroner released his Findings, it is inconceivable that Dr Manock would have been called to give evidence at Keogh’s trial, the credibility of any testimony he was to have given now shredded. If Dr Manock had not given evidence, Keogh would not have been convicted. There was no other evidence the prosecution could put to the jury.

Following Keogh’s conviction (eventually overturned in 2014), the Coroner within days released his findings. By all the rules of legal process, his Findings concerning Dr Manock should have then resulted in an instant acquittal of Keogh, on the basis of inadmissible forensic evidence. The law in Australia states that if information relevant to the credibility of a Crown witness is not made available at trial, then that is sufficient for the verdict to be overturned.

legal system failed

Not only were the criminals responsible for the infanticide of three babies never pursued by the police, but an innocent man was convicted of murder; the Coroner withheld exculpatory evidence and the legal system failed in its duty to adhere to the rule of law.

Another officer of the Crown made an equally poor decision – one that prompted the affidavit by Sykes. In 1996, after the failure of his first appeal to the Court of Criminal Appeal, Keogh instructed Michael Sykes, to take over his case. Mr Sykes contacted Mr David QC, who was by then a Judge of the District Court of South Australia, in the following terms:

“I asked Judge David if he would make an affidavit deposing to reasons as to why he did not raise in the appeal any issue relating to the Baby Deaths Coronial Findings by the Coroner in relation to Dr Manock. Judge David declined. He informed me that once they were published he had considered them, but could not see how they could assist Keogh. As the Findings only came out after the trial he did not have time to consider them in more than an embryonic level and was without the opportunity for an in-depth analysis prior to the appeal being heard. [There were some three months between the date the Findings were issued and the hearing of the appeal.]” Whatever ’embryonic level’ means, it was at best neglectful.

David “…could not see how they could assist Keogh”. Here is how: Dr Manock was not fit to have given evidence at Keogh’s trial, or any trial for that matter. The appeal would have been successful, saving Keogh almost 20 years in prison.

The error was repeated and compounded the hurt caused to Keogh – and to the justice system. The Coroner’s failure to make a timely disclosure so as to disqualify the unqualified Dr Manock testifying in the Keogh trial was the first of three major non-disclosure transgressions by officers of the Crown against Keogh. Some 10 years later, officers of the Crown failed to disclose another exculpatory report to Keogh: the report by forensic expert Dr Barrie Vernon-Roberts which also discredits Dr Manock’s crucial evidence, this time in the Keogh trial.

legal carnage in three acts

In the first instance, Coroner Chivell’s non-disclosure in 1995 helped put Keogh in jail; in the second, David QC’s  failure to use the Findings in Keogh’s 1996 appeal kept him there and in the third, the Crown’s non-disclosure of the Vernon-Roberts report in 2004 kept him there for another 10 years.

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3 Responses to The Baby Deaths chain reaction

  1. Chris says:

    Hi Andrew,

    Whilst there is no doubt that Dr Manock was a menace, I would not be too quick to assume that the infant deaths were due to traumatic events. The misdiagnosis of infant trauma, and conviction of innocent people (usually a grieving parent), has a long and sorry history in this country. In one case I am looking into and will blog about soon, a man was convicted in 2019 in Victoria for ‘shaking’ his son and causing brain injuries. Again based on the junk science pertaining to the ‘triad’. It turns out that the mother of the infant also has an acquired brain injury. I did some research and recently discovered that she was allegedly shaken when she was an infant, which resulted in those brain injuries. Her mother was accused by doctors of shaking her but has always denied it. Is there a genetic disorder? Doctors are supposed to look for genetic causes of the brain injuries associated with shaken baby syndrome; multiple different genetic causes are known, presumably multiple remain unknown. Can it really be a coincidence that both mother and son were shaken, both times without any witness or any other evidence, and both times by people who emphatically deny shaking? Or is this a tragic case of misdiagnosis spreading over two generations?

    • andrew says:

      The significant failure is that Manock failed to recognise and report the bruises and fractures in each baby, and as we note in the article: A detective from the CIB said that because he was told that the cause of death was bronchopneumonia, it meant that he couldn’t undertake further inquiries. I have no information as to whether the Coroner found any evidence of bronchopneumonia in any of the babies.

      • Chris says:

        Hi Andrew,

        I absolutely agree that the cases warranted investigation and have no doubt that the diagnosis of Madock was dodgy! I just also dont have much faith in doctors diagnosing abuse from certain injuries, without other types of supporting evidence. For example, bruises and fractures can be caused by resuscitation attempts, and there are also several conditions such as Osteogenesis imperfecta, some only discovered since the date of those deaths, that cause some infants to have fragile bones. So, I agree it was a failure and they should have been investigated but there is also the distinct possibility that there were natural causes other than bronchitis…

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