Andrew L. Urban
It was in the main street of Mintabie, 980 kms northwest of Adelaide, the remote opal mining community (now closed). It was 1978 and an Aboriginal man had been found dead, in mysterious circumstances. The Coroner sent a team to investigate. Refusing an offer of a cool room for the procedure, the State’s forensic pathologist set up a make shift morgue in the street and proceeded to perform his gut wrenching task. After Dr Colin Manock had removed the bodily organs from the chest, he used a ladle to scoop up some of the body fluids and quipped, ‘does anybody fancy a slurp?’
The report of this incident is part of an affidavit sworn by a former police officer who witnessed the event. That tabloid moment illustrates that Manock was unqualified for the job of the State’s forensic pathologist. Astonishingly, the State of South Australia knew this and did nothing.
The late Kevin Borick KC and Flinders University legal academic Dr Bob Moles have repeatedly over the years raised serious concerns about Manock’s unreliability and lack of appropriate qualifications – which caused extensive harm to the administration of justice in South Australia. We have published several articles detailing their concerns. Along the way, Manock’s path was strewn with serious failures by others in the legal system.
The Manock files:
Flinders University legal academic Dr Bob Moles has written extensively about Manock and has a dedicated section on his networked knowledge website. We have published several articles by him; this is one, calling for a Royal Commission. Giving explosive evidence before the Budget & Finance Committee of the South Australian Legislative Council (November 5, 2018), Moles outlined why he believes a Royal Commission is needed into the State’s several failures in allowing the unqualified and discredited forensic pathologist Dr Colin Manock to continue his work – unchecked for decades.
Dr Colin Manock and the Baby Deaths
Three babies who Dr Manock said had died from bronchopneumonia in fact had been beaten to death.
More pressure to mitigate Manock harm
In the case of Dr Manock, proper procedures have not been followed and the question of the outcomes in 10,000 autopsies and over 400 criminal convictions have been brought into question
How to fix Australia’s biggest legal scandal
Dr Moles and I (Urban) submitted to SA Attorney General The Hon Vickie Chapman that the State had to address Dr Manock’s legacy of forensic malpractice. For one thing, convictions based on his work were (and remain) all clearly unsafe. Those convicted have a right to be assured or relieved…. legally and morally. Many will have served their time, but the convictions remain on the record. Some may well have died, some will still be in prison, perhaps.
Our correspondence in 2018-19 included argument that being pro-active in the matter and tackling the issue head on would be in the public interest as well as politically advisable.
Chapman concluded the correspondence (19 February, 2019) thus: “I do not consider that investigation of the many cases in which Dr Colin Manock conducted pathology work over many years is necessary or that the associated expenditure of public funds would be justified.
I reiterate that any concerns arising from Dr Manock’s conduct or evidence will be appropriately dealt with on a case by case basis.”
In other words, it has been left up to the convicted and/or their families to begin proceedings to request a review of Dr Manock’s evidence. Individually. How fair is that? How practical is that? How does this decision sit with the administration of justice? How much confidence does it inspire in the justice system?
All par for the course in our wonderful legal system.
Jack: Would seem- the lunatics like poor old sick Manock and many others are running the asylum! Judges with a roo loose in the top paddock sitting on the appeals courts- keeping the obviously innocent in prison ! Jury fooling expertise is a team sport – judge / police prosecutor and flexable forensics. If we ever have a form of CCRC – will it be just a tooth less tiger with the occasional result to stop the peasants getting restless ?
It will never cease to amaze me that SA & Federal Governments don’t want to investigate & hold Colin Mannock accountable for his disgraceful behaviour. Not withstanding the thousands of people who had unsafe verdicts due to Colin Mannock’s findings.
Nothing Ventured, Nothing Gained: A Novel Legal Pathway to Systemic Justice in the Manock Cases
With the scale of Dr Colin Manock’s impact well understood, thousands of autopsies, hundreds of convictions, documented incompetence, and state knowledge of his lack of qualifications. The question is no longer, whether justice requires action, but how to force it when governments insist on case-by-case reviews only. Conventional routes have stalled. This essay focuses on an innovative, largely untested legal avenue: a representative (class) action seeking declaratory relief for systemic institutional negligence.
Nothing Ventured, Nothing Gained
The justice system itself rests on bold assertions of rights when institutions fail. Here, the innovation lies in shifting from fragmented individual appeals to a collective judicial declaration that Manock’s unqualified and unreliable work, combined with the state’s long-term tolerance of it, created a systemic risk of miscarriage of justice. Such a declaration would not quash every conviction outright (courts resist that) but would establish a legal and factual foundation for mandatory reviews, notifications, record corrections, compensation frameworks, and potential legislative remedies.
The Core Legal Theory
Draw on Dr Bob Moles’ extensive analysis: the South Australian authorities knew by the mid-1970s that Manock was not properly qualified to perform forensic autopsies or give expert evidence, yet allowed him to continue for decades. This was not isolated error but institutional failure, appointment, oversight, disclosure, and post-exposure inaction by forensic services, prosecution, judiciary, and government. Moles has argued this undermines the rule of law on a broad scale, warranting a Royal Commission. His work, including parliamentary evidence and publications, supplies powerful affidavits on systemic breaches of duty.
A representative proceeding in the Supreme Court of South Australia (or Federal Court) could define a class of affected convicted persons and families. The primary relief sought:
1. A declaration of systemic unreliability in Manock’s forensic work, coupled with state institutional negligence (or misfeasance in public office) in its appointment, supervision, and continued reliance despite known deficiencies.
2. Ancillary orders directing a structured review mechanism, data disclosure, legal aid funding for individual follow-through, and/or establishment of an independent redress scheme.
This thesis centres on systemic negligence declarations: proving that the state owed (and breached) a duty to maintain the integrity of forensic evidence used in criminal proceedings, with foreseeable harm to liberty, reputation, and fair trials. It leverages common issues (qualification deficits, flawed methodologies, institutional knowledge and inaction) while accommodating case-specific variations, consistent with Australian class action principles that allow group proceedings even where individual outcomes differ.
Supporting Precedents for Systemic Negligence Declarations
This approach, though novel in its specific application to a single forensic pathologist’s decades-long tenure in Australia, builds on established precedents for systemic challenges:
• Robodebt scheme (Australia): Federal Court proceedings addressed a systemic unlawful automated debt recovery program rooted in institutional knowledge of flaws. Declarations of illegality, combined with class mechanisms, led to massive settlements, repayments, and a Royal Commission exposing misfeasance. It demonstrated courts’ willingness to make systemic findings against government failures.
• UK Post Office Horizon Scandal: Group litigation secured High Court declarations on the systemic unreliability of the IT system and institutional misconduct in prosecutions. This triggered mass quashing’s, compensation schemes, and inquiries creating the precise cascade of relief sought in the Manock context.
• Goudge Inquiry (Canada, 2008): A public inquiry into paediatric forensic pathology (following flawed work by Dr Charles Smith) identified systemic failings in oversight, training, and practice. It led to comprehensive reviews of affected cases, reforms, and recognition that institutional tolerance of unreliable forensic pathology creates broad risks of miscarriage of justice. While inquiry-based, it underscores judicial and governmental responsiveness to systemic forensic negligence claims.
• Motherisk Scandal (Canada): Flawed hair-drug testing by a hospital lab affected thousands in child protection and criminal matters. A proposed class action alleged negligence in standards, oversight, and reliability. Though certification faced hurdles due to individual variations, it prompted an independent commission, case reviews, and settlements, illustrating both the potential and challenges of collective action against tainted forensic evidence.
Australian class action jurisprudence further supports this: courts can grant declaratory relief on common questions of law/fact, including liability for systemic negligence, even in complex institutional settings (e.g., product liability, regulatory failures, and government schemes). Representative proceedings explicitly contemplate varied individual outcomes provided common issues predominate.
Complementary Elements for Maximum Impact
• Targeted parallel actions: Judicial review or tort claims by high-profile plaintiffs, supported by academic amicus briefs drawing on Moles’ scholarship.
• Coronial reopening: Coordinated applications using any litigation disclosures as “fresh evidence.”
• Public and parliamentary pressure: Use proceedings to generate discovery, media attention, and petitions for a formal inquiry—framing government resistance as perpetuating injustice.
Why This Advances Victims and Accountability
It validates collective harm without requiring every person to litigate alone. A judicial declaration of systemic negligence creates moral, political, and legal momentum that case-by-case petitions cannot. It exposes the human and fiscal cost of inaction (future payouts, eroded trust) while offering a practical off-ramp: proactive redress schemes. For vulnerable groups disproportionately affected, it asserts that forensic reliability is a systemic right, not a lottery.
Success is not guaranteed, courts are cautious on broad criminal justice interventions but partial wins (discovery, adverse findings on negligence, or publicity) would dramatically raise the profile and pressure the SA government where political submissions have failed.
In matters of this magnitude, where the state has defaulted on its duty to ensure forensic integrity, innovation is not just justified, it is necessary.
Nothing ventured, nothing gained: the pursuit of this representative pathway, grounded in precedents for systemic declarations, could finally convert decades of documented failure into tangible, systemic justice.
Engaging specialist class action practitioners, leveraging Moles’ repository, and securing initial plaintiffs and funding (crowd, pro bono, or conditional) would be the immediate practical steps.
The legal architecture exists. The only question is whether it will be tested.