August 16, 2025 • 65 mins
How did a person die? That’s the question Hugh Dillon asked as he oversaw more than 300 cases during his career as Deputy State Coroner. Working in death investigation, the retired coroner has seen the best and worst of humanity. He joins Gary Jubelin to talk about some of the cases that he’ll never forget.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
The public has had a long held fascination with detectives.
Detective see aside of life the average person is never
exposed to. I spent thirty four years as a cop.
For twenty five of those years I was catching killers.
That's what I did for a living. I was a
homicide detective. I'm no longer just interviewing bad guys. Instead,
I'm taking the public into the world in which I operated.
(00:23):
The guests I talk to each week have amazing stories
from all sides of the law. The interviews are raw
and honest, just like the people I talk to. Some
of the content and language might be confronting. That's because
no one who comes into contact with crime is left unchanged.
Join me now as I take you into this world. Today,
(00:47):
I had the privilege of sitting down having a chat
with former New South Wales Deputy State Coroner Hugh Dylon.
I say privilege because Hugh shares a passion very much
aligned with what I considered the most important I had
as a homicide detective. That was looking after the families
of people who have died in the tragic, violent and
unusual circumstances, bringing whatever comfort possible to the deceased. Families
(01:11):
by providing answers as to what happened to their loved
ones and where possible prevent unnecessary deaths. Throughout his career,
Hugh presided over more than three hundred inquests, including the
horrific School of Happiness case where one man hunted police
with a crossbow in the middle of the night during
the Hippie festival. He also oversaw murders, suicides, and tragic
(01:35):
accidental deaths.
Speaker 2 (01:36):
As you'll find.
Speaker 1 (01:37):
Out in our discussion, the coroner's court is filled with sadness.
In the motion, Hugh takes us through the cases of
the oversaw, how the system can be improved, and the
personal impact of dealing with death on a daily basis.
Hugh Dylan, thanks for coming on I Catch Killers.
Speaker 3 (01:55):
It's a great pleasure. Gren very nice to see you again.
Speaker 1 (01:57):
Well, it is good to see you, and I always
I had a lot of respect for the role that
you did as a coroner, and you were the deputy
state coroner or is a coroner for nine years. Yes,
that's right, and in prepping for it, I believe that
you oversaw probably three hundred roughly three hundred question.
Speaker 3 (02:17):
Yeah, it's a bit hard to work. It out exactly,
but a round about three hundred, I'd.
Speaker 2 (02:22):
Say, yeah, it's a lot.
Speaker 1 (02:24):
And I don't think people fully appreciate the impact that
the coroner's court has. I found it in all the
areas of policing I work. That's when I saw the
most emotion at coroner's courts, because you're talking about someone's died.
That's generally what the inquest is about. And you've got
the families and loved ones there holding on to hope
(02:47):
or trying to get answers.
Speaker 2 (02:49):
Is that how you felt?
Speaker 3 (02:50):
Yeah, Look, it's a surprising place. It's a surprising niche
in the legal system, and most people in the law,
most people in society have no idea. But I can
remember the first day I went to the coroner's court.
(03:10):
I was a new magistrate and I was really surprised
by it. Apart from anything else. The coroners were doing this,
this kind of work that no other lawyers in our
society do. And also they're working in teams and as
you say, their concern is or who has died, how
(03:36):
they've died, why they've died, but also what can we
say to the families and the families My father was
a coroner's case himself around about forty years ago, and
I remember, I remember very very well getting the news
that he died suddenly, and the shock and the confusion
(04:00):
that that throws you into. So to walk into this
place as a coroner, and to try and grapple with
that confusion, the bewilderment, and of course the sadness was
somewhat bewildering to me as well. But Garry I really
(04:22):
liked being a coroner, and some people would be astonished
to hear me say that, I guess, because of course
you're right. It is a very sad place in lots
of ways. Families are devastated, they're confused, one answers. Sometimes
they have interesting theories about how someone they love has died.
(04:48):
Some of those theories are right, but some of them
are wrong. And it's very difficult to walk people into
the evidence and through it and then bring them to
some sort of understanding, some sense of what happened. I
think some people might call this sense making, you know,
(05:08):
how do we make sense of these terrible events.
Speaker 1 (05:11):
There's a lot of expectation when people get to the
coroner's court. I saw that over the years with families
and it's almost like, Okay, the answer is going to
be forthcoming when the matter gets to the coroner's court,
and I think meeting the family's expectation or that's a
difficult part too, because sometimes the facts don't present the
way the family expected it to, and quite often the
(05:34):
evidence that is given at a coronial inquest is quite
confronting to the families and loved ones of the deceased person.
Speaker 3 (05:42):
Well, that's right, And although you're always very glad as
a coroner if you have found the answers, there are
lots of cases where you don't, and you, as a
homicide or an ex homicide detective, would be very familiar
with some of those cases. You know, there are unsolved
homicides as well as you know all the I want
(06:05):
to call them happy endings, but they're cases in which
there is an answer for people. And to leave people
without answers is it's not only very frustrating, but it's
also very sad because you can't help empathizing and feeling
for them but also with them. You know, if you
(06:27):
lose a daughter, you know, I'm thinking about my daughter
as I'm talking to you about you losing yours. What
a shattering and incomplete kind of sense of life you
might have. So, as I say, sometimes you can provide
(06:47):
answers and that can give people a sense of resolution.
I don't believe there's any such thing as closure. I
think that's a false hope.
Speaker 1 (06:57):
I'm glad you say that, and that tells me you
understand the situation that families go through. And I got
clipped very early in my career when use the word
closure to a family and they pointed out very very
clear to me, it's not the closure. You never get
closure from that. And that's what happens when and it's
not always homicide. If someone's I would find that in
(07:22):
the courrner's court. Those tragic accidents are hard to deal
with too, because I look at homicide and often the
families can allocate blame to a particular person. Where there's
accidents where there's the fault, like there's built up anger
and sadness and that it's nowhere to channel it.
Speaker 3 (07:41):
That's right, and I think the families of missing people
have a particularly onerous load to bear. I guess if
you can bury your your loved ones, you can have
a sense of not camp or anything like that. But
(08:01):
you can say goodbye, but all you have is your
last memories of them, and then they disappear off the
face of the earth. How do you deal with that?
I really don't know, and I never really learned how
to how to give people a sense of peace or
(08:23):
any sense of forward movement. I think the only thing
you can do for people where their loved ones disappear
is respect, recognition. You know, we will do our best
to find out what happened, but sometimes the answer is
(08:43):
beyond reach.
Speaker 2 (08:44):
That's not there.
Speaker 1 (08:45):
I saw with families on missing persons cases quite often
that I felt like it was a step that helped
them in processing what had happened when the coroner would
declare the person deceased. Because what I've seen with families
and friends of people who have just disappeared, they always
hang on to that smidge and of hope that the
person's going to walk through the door one day and
(09:08):
they're going to yell at the person, go what have
you done? And then they're going to give each other
a big cuddle and get on with their lives. So
I think sometimes they hold on to hope, and quite
often I've seen it in cranial inquest where the coroner's
declared the person deceased manner and cause might have known,
but believe that the person is deceased because of checks
(09:29):
that have been done, and I feel like it's a
step forward. But the coroner's court I always found the
expectations were high by the families. It was a lot
of it's built up like if the investigation into the
death of someone hasn't revealed the information or the person responsible.
Quite often the hope is, well, we'll get the answers
(09:50):
at the coroner's court. But that's not always the way,
and that must have carried hard on you being a coroner,
that the family is steering. But where else do we go?
And the sad part is sometimes there is nowhere else
to go after the coroner's court.
Speaker 3 (10:02):
Yeah, and it's very frustrating. And from time to time
I think coroners I think they fail people by not
saying what they really think. Sometimes, I think, and I've
seen this happen, particularly within experienced coroners, they will simply
(10:24):
because they know how sad people are and how hard
it will hit them. If you say I think your
loved one is dead, they say, oh, well, you know
the evidence isn't quite sufficient, so maybe they're still soften that. Yeah,
And I to be honest, I think that does not
(10:47):
help people cope with what has actually happened. If someone
has disappeared and they've I mean very occasionally people do
turn up. I know, we all know that, but it
is so rare. It's just once in many, many blue moons.
And I think as a coroner you have a duty
(11:09):
of care both to the dead in respect to them,
but also to the families to be upfront with families
and say, the investigation has got this far, we don't
know precisely what happened, but your loved one more than
likely is dead. We can't prove it beyond a reasonable doubt,
(11:31):
aps but it's almost certain. So that's all we can do.
Speaker 2 (11:36):
I think.
Speaker 1 (11:36):
I think that's kind of false hope. Can be a
very cruel thing if false hope is offered out. So
I think roll of a coroner and that is quite
often the final step for families trying to find out
what's happened to their loved one, especially with people who disappeared.
Tell us what was your story into becoming a coroner?
Speaker 2 (11:56):
Ah?
Speaker 3 (11:56):
Well, I obviously did a law degree in Australia, coroners
are lawyers. In New South Bales, they're all magistrates. I
did some legal research, I worked for a judge, I
worked for the New South Bale's ombudsman, and then I
got a job as a Comwealth prosecutor. So I worked
for the Commonwealth DPP for a number of years. Then
(12:20):
I was appointed a magistrate. Did about twelve years as
a magistrate and I was on the point of leaving
the magistracy and my friend Mary Durham, who was the
new state coroner, heard that I was contemplating leaving and
she got in touch with me and asked me whether
i'd like to have a go as a coroner. And
(12:44):
to be honest, I thought, oh my god, this is
so depressing, this kind of work. But I really liked Mary,
and she said, well, she said a few flattering things
about me, so I found it out to say no
to her, to be me very forthros, very forthright. She
(13:04):
also is very persuasive, and I thought, okay, well, I've
put off going to the bar for six months, I'll
go and see what this is like. You know, all
experience is good experience, and I really when I got there,
I really liked the work, partly because I was working
(13:25):
with really good people like Mary. But one of the
things i'd really missed as a magistrate was working in
a team. And Gary, you know what it's like working
in teams most homicide cases.
Speaker 2 (13:40):
You share the pressure, so the pressure.
Speaker 3 (13:42):
But it's also sharing ideas and a community, a small community,
a team can generate more ideas than a bunch of
single individuals, definitely, and so strangely enough, although the work
could be very confronting and very sad and saddening, I
(14:08):
really enjoyed working with the team of people I was
working with. So instead of leaving after six months, I
stayed and I just stayed on until basically the chief
magistrate said, well, your time's up. You've had enough time
here and you're coming back to the local court. And
I thought, well, no, I'm not. I like being a coroner.
(14:32):
I don't want to be a magistrate anymore. So that's
when I.
Speaker 2 (14:37):
Left, decide to leave.
Speaker 1 (14:39):
It's funny that you get rotated, or a tap on
the shoulder that you've been there too long. I would
imagine something in the role of a pathway as a coroner,
you'd be learning all the time. Yeah, yeah, you'd be
learning how not just the processes in place, but how
to deal with families and all that. I could imagine
(14:59):
every day you went to work.
Speaker 3 (15:01):
Look, I think that's absolutely right. And I remember saying too,
we had this rotation, three year rotation thing, and I
remember saying to the Chief Magistrate, I don't think I
was any good at this job until I've been in
it for two years, that makes sense. And then so
three years I'm just starting really to get good at it.
(15:25):
And I thought I wasn't an expert coroner until i'd
been doing it for five years. But look, after I left,
I've done further study. I've done a PhD, which is
a study of then you Saitho's coronial system, and I've
learned so much more. So I know that you're absolutely right.
(15:47):
Nine years I was learning all the time, and since
I left the Coroner's Court, I've been learning even more.
So you need to stay in these jobs to get
really good at that.
Speaker 1 (15:57):
Well, it is a specialist field. I would imagine that
the role of a magistrate as compared to the role
of a current is vastly different.
Speaker 3 (16:05):
Very very different. A magistrate's job is primarily running small
summary trials and sentencing. So some days you sit in
a court and sentence people who are pleading guilty to
various things. Other days you have hearings. You might do
bails and apprehended violence applications and that sort of stuff.
(16:31):
After a while, it becomes very repetitious. You'd become to
be perfectly honest, I think I was quite a good magistrate.
But practice makes perfect and you're doing a lot of practice.
So after a couple of years of that, I think
I was pretty pretty good at it. After five years
of it, I really needed a change, and so I
(16:52):
did civil civil cases mainly. And again, it took me
about five years before I thought I was experted that,
and then the coroner's job came on.
Speaker 1 (17:04):
Okay, can you explain what the role of the coroner's
court is? So I obviously aware of it, but if
you could explain to the listeners, because I think there's
a misconception on some of the aspects of coroner's courts
what their role is.
Speaker 3 (17:17):
If you could explain, it's death investigation, So if someone
dies suddenly or in an unexplained or difficult to understand way,
or due to an unnatural cause, accidents, suicide, homicides, these
(17:37):
sort of things in our society, and since the twelfth
century actually there have been coroners who investigated these sudden,
unexplained or unnatural deaths. The coroners are one of the
oldest legal institutions in the world and so Australia imported
(17:59):
coroners when first Fleet arrived. The first in quest in
Australia was in December seventeen eighty eight a convict diet
and a inquest was held. And so we've had this
two hundred and fifty odd years of people inquiring into
how a death came about. And it's a very different
(18:21):
process from a criminal trial, as you're well aware.
Speaker 1 (18:25):
If you could break that down as well, because I
think people think sometimes it mata goes to the coroner
and the coroner could find this person guilty of in
the fence, but that's not the case at all, and
that's a whole different set of rules.
Speaker 3 (18:36):
Well, even if you think a person is guilty of
criminal offense, you have no jurisdiction to decide that. That
has to be decided elsewhere by that first of all,
by the DPP and then by a criminal court. But
to go back, what's the process. Well, first of all,
I talked about teams. The coroner's seigners work in a system,
(19:01):
a coronial system, and it's a multidisciplinary system. You were
part of it. I was part of it. Forensic pathologists
are part of it. Family counselors, support people, administrators, etc.
Are part of it. But the first thing that happens,
of course, is that someone reports a death, and that's
(19:21):
usually done by police officers. So police might be called
to a hospital because someone's diet of injuries or something
like that. The doctors will report to the police, the
police will report to the coroner, and then there'll be
a medical examination. The coroners and the forensic pathologists will
(19:45):
decide how to examine the person's body for evidence of
the physiological or the medical cause of death. So that's
the first stage. Of course. Families are notified and there's
a whole process of informing them, which is a shattering event,
(20:06):
as I was talking about a little while ago, really
shattering event for people. So there's a process of talking
family members into this strange process. They may have heard
about or may not have heard about, but most of
(20:27):
them will never have experienced before. So how do you
bring people into that. That's part of it. So we
have a team. We had a team at the Corners
Court family Support team and the forensic pathologists also had
social workers who are dealing with families. Then we have
(20:49):
police involved. If the circumstances of a case look like
they're unnatural, if the cause of death is looks like
it's unnatural, then the police will do an investigation on
behalf of the coroners. Sometimes that will look like a
homicide investigation, and if it is a homicide, it'll be
(21:10):
a very very thorough investigation. If it's an accident, there
will also be a police investigation. There may be other
experts called in aviation experts or all sorts of people.
If someone takes their own life, there will also be
a police investigation, and that will be somewhat different from
(21:32):
a homicide investigation because clearly, not only has a person
whom other people love died taken their own life or
apparently so, the family will be so psychologically shaken by
this that they need real care. And that's difficult because
(21:56):
the first responders will usually be young. Police office is
followed by detectives. The detectives are usually much more experienced
and have seen terrible things usually, but there are lots
of things going on in those scenarios, the shattered love relatives,
(22:21):
but also what happens to the young police officers who
are possibly seeing these sort of scenarios for the first
time in their lives.
Speaker 1 (22:31):
Yeah, you mentioned you mentioned the police and what we'll
talk further about that later on, but the impact of
police because we mentioned at the start the full range
of emotions and the heavy emotional toll inquest take. But
there's a lot of people that are affected by it.
On the issue of suicides too, they're difficult ones. And
(22:51):
I know from earlier because quite often the family don't
want to accept that someone's taken their own life, so
their minds.
Speaker 2 (22:59):
Sticking over it.
Speaker 1 (23:00):
You know, there must be something more to this, so
you're dealing with that aspect of it as well.
Speaker 2 (23:05):
But yeah, it's.
Speaker 1 (23:07):
Confronting the whole range of things. And then accidents. The
purpose of investigating an accident is to find out ways
of preventing that accident from occurring. Again, that's something that
the coronial process is involved in as well.
Speaker 3 (23:23):
That's rightight, And although I think we do that quite
well in in a lot of cases we only hold
about it one hundred inquests a year in the South Bales,
but there are eight thousand or roughly eight thousand deaths
reported every year, so and around about forty percent of
(23:43):
the reported deaths to unnatural causes. So we don't really
investigate enough enough accidents, I think to learn all the
lessons that could be learned. Ideally, a cronial system should
really thoroughly investigate all the accidents that occurred, that fatalities
(24:10):
and try and put them into patterns or identify trends
so that we can we can pull out life saving lessons.
One thing that people don't often think about, and frankly
I didn't think about when I was a coroner, but
I have thought about since is the economic value of
(24:30):
a human life. The Australian government puts an economic value
on an Australian life. It's called the value of a
statistical life, and that in twenty twenty four it was
estimated to be five point seven million dollars and a
(24:50):
life year is valued by actuaries at around about two
hundred and forty or two hundred and fifty thousand dollars.
So investigating thoroughly the causes of accidents should be regarded
as an investment in life saving because if we could
(25:12):
save more lives, if we could prevent more accidents, then
it would be obviously good for the families and the
community in general if this human cost wasn't spent or incurred.
But there's also a value to the economy. So if
(25:33):
you think about it, three thousand unnatural deaths a year,
that's possibly fifteen billion dollars just putting it in dollar terms,
which is a very crude an unsatisfactory way to put it,
but it's really worth looking at. This is not just
(25:54):
a lot of grief and a lot of sadness. It's
an enormous cost to the society that we live.
Speaker 1 (26:01):
In that we've lost the life these things like I'll
pluck this as an example because it's fairly topical at
the moment or current, like eese scooters, when there's a
death on an new scooter, we see that these scooters
on long foot paths, or the role of a coronario
would imagine I'm talking hypothetically here, is if there's a
(26:23):
series of accidents in quests, Okay, well how did this accident?
There might be recommendations like the helmet recommendation there is
an obvious one or not the right on footpaths or
certain things that might prevent deaths as well.
Speaker 2 (26:35):
That's the role of a corona.
Speaker 3 (26:38):
Yeah, and ideally most in quests would result in recommendations
to public health and safety officials who would then work
through the practicalities of their I mean coroners are not
engineers or those sort of things. But a good in
quest should bring in experts, experts, that's right. And then
(27:04):
and very often families also have good ideas about how
to because they've given a lot of thought to how
their loved ones have died. They often have good ideas.
So in New South Wales, if we could increase the
number of cases in which recommendations were produced, or if
(27:24):
we could identify more patterns and trends of fatalities and
serious injury, then we would have a more effective and
more productive coronial system than we have at the moment.
Speaker 1 (27:38):
Is there any accident you've seen that's really stuck in
your mind?
Speaker 3 (27:43):
Well, one of them is a terrible collision on Sydney
Harbor which I spent some weeks inquiring into. Yeah, that
was very very interesting.
Speaker 1 (27:58):
Is that the one where for people were killed.
Speaker 3 (28:02):
Four people were killed. There were passengers on board a
pleasure cruiser which was proceeding from west towards towards Circular Key,
and a river cat ferry came out of Circular Key.
It was on its way back to the Balmain dockyard.
(28:24):
Were at Birthed Yep and right under the harbor bridge
on the on the southern side. The boat was run
over by the by the ferry.
Speaker 1 (28:36):
How many people were on the boat, I can't quite remember.
Speaker 3 (28:39):
I think it was around about nine people.
Speaker 2 (28:41):
Right, and four.
Speaker 3 (28:42):
People were killed.
Speaker 1 (28:43):
Yeah, what was it about that stuck in your mind,
that that particular matter.
Speaker 3 (28:50):
Well, there were a number of things. Really. My council
assistant and I and my team went out on Sydney
Harbor and you know, it took a view as it were,
and we went up that the river with you know,
in a ferry in a river cat. The father of
a young dancer who was killed was representing his family.
(29:15):
He didn't have a lawyer and he was on the
he was on the ferry trying to talk to me.
And one of the one of the difficulties you have
if you're a coroner, as you you can't really talk
to the lawyers and the families in the course of
either taking a view or taking evidence of that sort
(29:35):
of thing. And I could see this poor man really
trying to understand what the hell are these lawyers up to?
You know, why can't I talk to the coroner? And
my council assistant was trying to say, look, the coroner
is very, very interested in what you've got to say,
but we've got certain rules about all of this sort
(29:57):
of stuff.
Speaker 2 (29:58):
So that was one thing just on that.
Speaker 1 (30:02):
It's difficult, isn't it, Because I know I've seen at
scenes and locations circumstances like that, and the coroner's there
and you've got the families there or the people that
have a vested interest in the situation. Obviously they want
to speak to speak to the coroner, but you can't.
You've got to have that independence that you're not speaking
(30:22):
to them directly or on specifics of the evidence.
Speaker 2 (30:24):
Yeah.
Speaker 3 (30:25):
Actually, since I've finished as a coroner, I've given more
thought to this, and I wonder whether sometimes coroners might
not be better off at least having a meeting with
the family with representatives or you know, someone to ensure
that you don't make any false promises or cuddle up
(30:49):
if you like, become biased towards families. But I wonder
sometimes whether we could do more to show the family
is that we actually care about them as well as
care about finding out what the answer to the question
about how their loved ones died.
Speaker 2 (31:10):
It carries a lot, doesn't it.
Speaker 1 (31:12):
If the families know that you care, whether that's a
police officer or a coroner, a legal person or anyone
that gets caught up in these situations. If there's you're
showing that you care, that can help the family so much.
Speaker 3 (31:25):
Well, I think so, And sometimes not always, but sometimes
after an inquest I would step down from the bench
and I talk to the family. That's after I've given
the decision. And I remember a particular case, I was
doing an inquiry into an inquest into a murder suicide case.
(31:48):
A father who had separated from his wife had taken
his three children off in a car and put a
I won't describe what happened, but anyway, he killed himself
and the three kids. The mother came to the court
and this was I think three years after the murder suicide,
(32:15):
and she was pregnant. She had repartnered since and after that,
and she spoke about how much she missed her children,
and so on and so forth, and I just admired
this woman so much, her courage in not only putting
up with what had happened. And as I said, I
(32:35):
don't think there's any such scene as closure. That she'd
managed somehow to face the world and go forward, and
now she'd repartnered, and now she was bringing new life
into the world. And I just thought, respect, and I
spoke to her and I said, how do you do this?
(32:58):
And she said, look, I'm not going to let this
guy get away with killing my kids. I'm not going
to be crushed by it. I'm not going to allow
him to destroy the life that I had. I'm going
to give new life. And I just thought, Wow, she's amazing.
(33:21):
And very often I saw things like that happen in court.
Speaker 1 (33:26):
I'm sure you took strength and the inspiration from the
way some of the families conduct themselves. So that's what
I saw, and I thought where I would often think,
where do you get that strength, whether you get that
strength to carry on? And also they can even see
joy in life, like the ability to get through as
you just described with the mother there, that she's going
(33:49):
to live a life despite what's happened.
Speaker 2 (33:51):
That's right.
Speaker 3 (33:51):
And some people are obviously very angry and they never
really get over their anger. But some people can be
remarkably forgiving. People can make mistakes, and sometimes those mistakes
cause deaths by a mission or commission. So sometimes you know,
(34:13):
for example, nurses or doctors miss clues. Let's suggest a
child is very, very sick and needs some sort of
virgent intervention, and by the time there is an intervention,
it's too late. I remember a case involving a little
boy who died and he'd been seen by well by
(34:37):
the time he died, he had been seen by six doctors.
The last two doctors realized what was happening and tried
to give emergent care, but the four previous doctors thought
he was sick but had a flu or some sort
of viral thing, but he'd get over it anyway. In
(34:58):
the inquest, some of the medical and health practitioners, once
they had finished their evidence, turned and faced the family
and said how sorry they were. But there was one doctor,
young doctor, and I still feel quite sorry for her,
but she couldn't bring herself to apologize. And I don't
(35:20):
know why not, but I really feel that she lost
an opportunity because the family were very willing to forgive
all these other people who did apologize, and I just thought, gosh,
if you turned and said you were sorry, that this
(35:41):
had really affected you as well. And I'm sure she
was affected, but maybe she got legal advised. You know,
I don't speak. Who knows. Maybe she just couldn't bring
herself to say anything. But I just thought, if you
could turn around and talk to them, I think it
would make both of you, the family and this doctor
(36:05):
so much happier than they were.
Speaker 1 (36:09):
I think you've just encapsulated when they talk about the
emotion that comes in the corner's court, just with that
one story that's on the thing that lives are shattered,
and it's about how people move forward. But I think
you might be right, And yeah, saying sorry can often
be the thing that helps people move forward.
Speaker 3 (36:29):
Can I tell you another story ago?
Speaker 2 (36:30):
Yeah?
Speaker 3 (36:31):
Yeah, this one had a happier ending. Really a young woman,
she was nineteen years old. She got very sick. She
was working on a sharing team somewhere in the southwest
of New South Wales and it looked like she had
a flu. So her boyfriend, who was on the team said,
(36:51):
go to bed. The sharing team boss was this marry guy.
Little murry guy said, going like and she just got
sicker and sicker though, and at some point in one
of the breaks, her boyfriend went in and saw him
and thought, oh my god, she's really sick. So they
(37:12):
called an ambulance, but it took nearly an hour for
the ambulance to get there. It was way out somewhere.
They got it to the hospital, but she was very,
very sick, and despite getting urgent attention, she died. We
held an inquest because one of the difficulties was there
(37:32):
wasn't a clear diagnosis of what was killing her, and
we still don't really have an absolute diagnosis actually, but
in any event, we held the inquest and her father,
who was a Victorian farmer, very big man, six foot
four or something, came in and we went through the evidence.
(37:57):
The family was represented by a very good arrister from Victoria,
and I had a very good counsel assistant. You may
know her, Peggy dwy a Silk or so. It's the Victorian.
And one of the great things about this inquest I
thought was that there was no bitterness, and at the
(38:22):
end of the case, I gave my decision and my reasons,
and I explained how you know, what had happened, and
as best we could what the diagnosis we thought was
most likely to be. Give my decision. I walk off
the bench. I'm sitting in my chambers, and Peggy comes
out and says, Hugh, he come to the come to
(38:45):
the door of the court. So I got up and
I went to the door of the court and we
pulled it out in a little bit and there was
this enormous Victorian farmer with his arms around the little
Marory shearing boss, both in tears, both embracing, and both
so sad, but so happy to have this moment with
(39:10):
one another. They were both they both loved this girl, the.
Speaker 2 (39:17):
Mary.
Speaker 3 (39:18):
Boss was so devastated by her death. I mean when
he gave evidence, he was just weeping, pouring tears pouring
out of him, very very emotional, as was her dad.
And so there was this moment of cathasis. It doesn't
always happened some you know, some people walk away still
(39:40):
feeling angry or whatever. But this was one of those
moments where thought, today we did something good. And having
spent a lot of time in criminal courts, I can say,
I don't think on a lot of days I ever
walked out of a criminal court thinking today we did
something good.
Speaker 1 (39:58):
Well, yeah, there's not not many people walk out happy
out of the criminal court. That if the person's convicted,
he or she's angry. If the person gets off, that's
the police or the prosecution angry.
Speaker 2 (40:11):
But the way you've.
Speaker 1 (40:12):
Described that, I can picture it, and that is doing
something good, like.
Speaker 2 (40:17):
True.
Speaker 3 (40:17):
And it was a moment of grace really, you know,
there's there's very generous hearted men were embracing each other
and owning the loss that they both felt.
Speaker 1 (40:33):
Yeah, and you could imagine the types that you're describing,
they could bottle it up. But the fact that they
let the emotion go, and you see that quite often
in the coroner's court. It is it is that emotional place.
The breakdown of the adversarial system for the criminal courts
and inquisitorial for the inquest. What's the difference in the
(40:54):
way that evidence is allowed into those courts.
Speaker 3 (40:57):
Well, the two things rely on different ways of thinking.
So in a criminal trial, one party the prosecutions as
a theory a hypothesis. The hypothesis is you Gary have
murdered me Hugh, you deny that allegation, and either prosecutor
(41:25):
have to try to prove my hypothesis. And I do
that by producing proof which I hope will satisfy people
in the jury beyond a resumal doubt that this is
the only reasonable answer you could come up with. That's
deductive thinking. The other way of thinking is inductive thinking,
(41:47):
which is to say, we look at all this evidence,
which may be scattered and fragmented in different ways, and
we try and come up with a theory. What theory
may sense of all this stuff that we have collected.
So that's theory building or inductive thinking. Now, of course
(42:12):
the adversarial side. There is an adversarial side to inquest
and you've experienced that, and that's where people who have
a different theory or have a particular theory challenge the
range of theories that have been developed. So current might thinking, okay, well,
the possibilities available for me are suicide, homicide, jumped off
(42:40):
a cliff, fell off a cliff, accidentally, was kidding up
by by by martians and assaulted who knows what. So
there might be a range of possible theories, and some
of the people who have an interest in this it
might be police, or it might be persons of interest
(43:01):
as we call suspects might want to challenge some of
these theories because they don't want the coroner to ultimately
settle on a particular theory that blames them. So there
is a degree of adversarialism in it in it or
(43:21):
can be in an inquest. But it's all about really
this inductive thinking. What is the most satisfactory theory we
can come up with that explains this death and the
circumstances that surrounded it, And that means you have to
look as carefully as you can at the surrounding circumstances,
(43:44):
and that might mean that you take a wide look.
Speaker 1 (43:47):
Does that allow for opinions to come in? Yes, because
rare in the criminal court that you get off your opinion,
but in the coroner's court, quite often opinions the coroner
takes that account.
Speaker 3 (44:00):
Opinions can be very important and they can be quite persuasive.
And also hearsay evidence. So here's some heresay evidence. Obviously
can get into a criminal trial, but only under very
limited circumstances because there are questions about the reliability of
(44:20):
hearsay and of opinions. Juries have to come up with
their own opinion about whether someone's guilty or not. That's
the idea about opinion evidence unless it relates to some
sort of area of X that's beyond common knowledge, etc.
But coroners are running an inquiry, not a trial, and
(44:44):
that's the fundamental difference. And that's what I'm saying inductive thinking,
that's I'm thinking about, what's the question, How do I
answer the question? What's the theory I can come up
with that answer answers the question question is how did
this person die? How did this death come about? What
(45:05):
explains it? But if we go to a trial, the
prosecution thinks it knows the answer to that, then it's
got to persuade a jury to agree with that answer.
Speaker 1 (45:18):
I'm just reflecting back on my first experience at an inquest,
and I think it was even in my uniform days,
where a young child, the mother was in the bathroom
and the hair dry fell into the bath. The two
kids in the bath just toddlers, and one died and
one survived from that. And I remember, and this was
(45:42):
probably the first sort of situation I've been to like
that where a brief had to be put together for
the coroner, So we put together a coronial brief. A
lot of questions were asked by what sort of system
did they have in the fuse box with the electrical work,
wasn't the safety Why didn't the circuit break a trip
at the time, and think like that long time ago.
But I think some recommendations came on the back of that.
(46:05):
That's the type of incident that would be bought before
the coroner.
Speaker 3 (46:10):
Yeah, definitely, And it's the very kind of incident that
should be brought before the coroner because there's obviously if
you explore that scenario thoroughly enough, there are there's real
potential for saving life in future.
Speaker 1 (46:28):
And warning's about electrical appliances near the bath and where
powerpoints are located near the bath.
Speaker 3 (46:34):
All of that, and yeah, well I would imagine a
good coroner came up with a number of recommendations, and
no doubt the police, which might have been you Gary,
contributed to that thinking process.
Speaker 1 (46:49):
It was I remember it because it was such a tragic,
tragic accident, and that's what it was.
Speaker 2 (46:55):
It was an accident.
Speaker 1 (46:56):
But whether the accident could have been safeguarded against by
you know, putting things in place or just letting people
be more aware of the situation. Another one, and I'm
just reflecting on all the different experiences I've had in
a coroner's court. The bower of all matter, you're familiar
with it, and people that have listened to the podcast
would be familiar with it. The murder of Evelyn green Up,
(47:19):
Colin Walker, and Clinton Speedy in nineteen ninety and ninety one.
Over a five month period, a person had been a
charge with one of the murders, went to court and
the person was acquitted. I became involved in a reinvestigation
and we just saw that we reinvestigated. We thought we
(47:40):
had enough information for the matter to go back before
the courts for the other two because the double jeopardy
legislation wasn't in on the other two matters that a
person hadn't been charged with, but the DPP knocked it back.
We then went to an inquest and had an inquest
where it was the first time witnesses in regards to
all three matters had provided any form of evidence in
(48:02):
a court environment because the person that was charged with
that crime was only dealt with the facts relating to
the murder of Clinton Speedy. We've gone to the inquest.
The inquest ran over a number of weeks. Everyone gave
evidence and there was opportunities for people to be cross examined.
(48:24):
On the back of that, I think it was John Abernathy,
was a coroner at the time, made a recommendation to
the DPP that he has reasonable cause that the known
persons involved in the matter and that all three matters
should be looked together. On the back of that, the
DPP then a little bit down the track, but the
weight that was carried from the inquest and John Abernathy's
(48:48):
recommendations decided to exo fishao, indict diet the person. I
raise that as an example because that's where I see
the coronial court working in an investigation. In that gave
the witnesses the opportunity to give evidence in a court
room environment, and then an assessment could have been was
made on the weight that could be placed on the evidence.
(49:10):
Is that how you see a coroner's court can be used. Yeah.
Speaker 3 (49:13):
And in fact, in New South Wales, if a person
has died and homicide is the suspected cause of that
and death and inquest is mandatory and so yeah, I
was thinking about this the other day. I'm quite sure
how many homicide inquests I did. It's probably I would
(49:36):
say probably twenty CYCA. In some cases I did refer
cases to the DPP. In other cases we didn't get
far enough. And in fact, the very last case I
did as a coroner was in Newcastle. It was a
double murder and we we had a person of interest
(50:02):
who gave evidence, but there simply wasn't enough evidence in
my opinion, the opinion of my counsel assisting or the
police investigators to refer to the DPP. An interesting, very
interesting case. Yeah, And you know, you never know. Sometimes
(50:25):
people say things or do things which pushes a case
where the DPP has doubts that the evidence is sufficient
over the line. And so a couple of a couple
of times I referred cases to the DPP after they
had initially decided there wasn't enough evidence. And sometimes they
(50:51):
put people on trial, sometimes they don't. Sometimes they take it.
You know, once they have a look at all the evidence,
they think, ye, that will work or not work.
Speaker 1 (51:01):
And I think that's what perhaps the public caren't fully
informed on that when the coroner maker makes a recommendation,
it's still that's not the end of the story. That
doesn't mean the person's going to trial. The DPP's got
to assess it from a criminal point of view, whether
there's sufficient evidence to warrant charges.
Speaker 2 (51:21):
Against a person.
Speaker 1 (51:22):
I suppose I lost my faith and I'm sorry to
say this when you're seeing here as a coroner, very
early in my career, but got it back. Naive young
detective working on a case. It was a brutal case.
A person had been shot with a shotgun and dumped
in the boot of his car, and his car was abandoned.
(51:43):
Locals called the police out. It was a horrendous, horrendous scene.
It was during the heat wave and the deceased body
was in the back of the boot for five days.
I remember the case well, I remember the post mortem.
It was a horrendous situation. There was what I considered
evidence a person person of interest. We won't mention the
names or the case. Young detective thinking, this is frustrating.
(52:07):
We know this person has done it, and it was
sort of suggested, let's take the matter to the coroner
and maybe further evidence will be forthcoming. What and I
knew this was a possibility, but it shocked me when
I saw it actually work. In the process, the person
of interest got in the witness box. We had presented
(52:28):
the brief to the coroner. I was excited as a
naive young detective, thinking, Okay, well this is We're going
to watch this person get carved up. He got in
the witness box and he was said, I declined to
answer any questions on the ground I might incriminate myself.
He got thanked by the coroner and left the court,
and it was sort of my expectations were high, the
(52:48):
family's expectations were. My expectations were high because I was
naive as the workings of the court. But I thought
there I just lost a little bit of faith in
that that write the silence. I fully understand the concept
of the silence, but a coronial inquest is to find
out what's happened to a person, and this person clearly
(53:09):
had relevant information about about how this person died, but
was allowed to just say I'm not going to say anything.
Speaker 2 (53:18):
What's your thoughts on that?
Speaker 3 (53:19):
I have mixed feelings about that from a purely coronial
point of view, Like everybody else, I would like to
hear the story from the person who probably knows most
about it. On the other hand, if there is a
strong case against a known person, I'd be quite reluctant
(53:42):
to force them to give evidence. The reason being that
if you force them to give evidence, they object, and
then you say no, no, no, you're going to give evidence.
They have to give evidence, and then they talk, but
whatever they say can be used, and it can't be
used in any way at all. So you can't be
(54:06):
used directly against them or indirectly against them, which is
even worse. So if you force someone to speak, my
view was that you run the real risk of jeopardizing
what may be a strong case at trial, because they'll
be able to say, oh, well, the cops went and
(54:28):
got this evidence.
Speaker 1 (54:30):
It's not just the evidence that provided can't be used.
It's a flow on, that's right.
Speaker 3 (54:35):
All the evidence that is obtained indirectly as a result
of them speaking is inadmissible.
Speaker 1 (54:42):
Well, I'm sure you are for me with the Matthew
Levison cases and that was an interesting I found that
an interesting case for a whole range of reasons. But basically,
and we've had Mark and Faye on the podcast, so
people have probably heard talk about the situation. Matthew disappeared.
(55:04):
He'd been out Saturday night at Oxford Street in Sydney
with his partner and disappeared. The partner was eventually circumstances
around the disappearance was a bit strange. They've waken up
and that Matthew's gone and the partner got on with
his life. And then Mark and fayr initi when they
(55:25):
were contacted by Matthew's employer he hadn't turned up for work.
They went to the police and reported that Matthew missing.
There was an investigation and I can say the name
that he hasn't been convicted of the murder, but it's
all public record. Michael Atkins, he's partner at the time,
was charged with murder. A murder trial was conducted, and
(55:46):
we should note that Michael Atkins was acquitted of murder
and manslaughter in two thousand and nine. So Mark and
Fayer left in and I'm sure you'd understand the situation.
Left in this horrible situation where they've okay, they've put
their faith in the justice system, it's gone the court
and then what have we got. Well, we've got no
answers because we've been told that this person wasn't responsible
(56:08):
for son's son's murder by the court during the trial
I became involved in it. They spoke to me and
we looked at okay, we could go to a cranial
inquest because and I think the representations they made to
the coroner were we put our faith in the justice
system as in the court system. We still don't have
(56:29):
answers for our son. Can we have a corannial inquest?
And on the back of that, there was a decision
that an inquest would be held. There was a lot
of layers to it, but it got to the point
where I was satisfied from a homicide to take this
point of view that we'd taken the investigation as far
as we possibly could. There was not going to We'd
(56:51):
gathered all the evidence of available evidence, so there wasn't
an opportunity because double jeopardy legislation had come in by
that stage. There wasn't going to be an opportunity to
reach uge because we hadn't gathered fresh and compelling evidence.
So then a bit of a conundrum. And you know,
Mark and Fay would on weekends go look for Matt's body.
They were desperate to get Matt's body back. And I
(57:12):
still remember having the conversation with them about what do
you hope to achieve from the inquest? And I think
it was Elaine Truscott was the coroner and very very
considerate of everyone's feelings and the appropriateness of the whole
way the matter has been run. And the decision was
made to give Michael Atkins a Section sixty one certificate
(57:35):
so that he could and when the listeners hear this,
they think this is ridiculous. But he could have got
in the witness box and said, yes, I murdered Matthew
Levison and this is how I did it, and that
we couldn't use that evidence.
Speaker 2 (57:48):
But that's the.
Speaker 1 (57:49):
Deal that we made a lot of processes that we
had to go through to do that, and it was
contested at court and Michael Atkins's defense were doing a
great job in protecting them. Eventually a decision was made
that he could give evidence with a section sixty one certificate.
He purjured himself whilst giving evidence in the witness box
(58:10):
for a week trying to answer questions and dodge around,
and then he was given the indemnity from the Attorney
General if he took us to Matthew Levison's body, which
he did. That's using an inquest in a way that
I don't think those said the circumstances would present themselves
very often. I know there was some sort of pushback
(58:32):
on people thinking, oh, well, are we really usurping the
person's right to silence? To me, I felt that it
was the right thing to do. I think Mark and
Fay have got their son's remains back. No one's been
charged with the murder. I'm just interested in to getting
your thoughts because I know it caused some different opinions.
(58:52):
I won't say controversy. Everyone wanted to see it resolved
in some way. What's your feelings on that?
Speaker 3 (58:59):
Yeah, well, and I've talked to various people about this.
Some people I know and respect, some lawyers I know
and respect very much don't like it at all, for
the very reasons you've just explained that it seems to
run against the ethos of our criminal justice system. On
(59:23):
the other hand, I couldn't help feeling for the Leveson
family to be honest, to get their son's body back,
to be able to bury him, to at least get
some idea of what actually happened to him. I think
was worth the cost. In that particular case. There's are
(59:48):
very rare circumstances, and I don't think the principle that
people are concerned about of protecting people's right to silence
is in any way undermined, and in fact, in some
ways it's strengthened, I suppose, because it's shown that if
(01:00:09):
you if you force someone to speak against the against
their own interests, to tell the truth, in other words,
then there is a price to pay for that. And
you know, when you when you go back and think
about the right to silence, it goes back to the
days when if you were found guilty of an offense,
(01:00:31):
you were hung for it. So obviously there had to
be some protection against people being hung on the evidence
that came out of their own mouths. You know, that's
torturing people, really, one way or the other. So I
fully support the right to silence, and you know, would
always do that, but I think in this particular case,
(01:00:54):
and I really respect Elane, trust God as well as
a human being, as well as as well as a coroner,
I think she made the right decision.
Speaker 2 (01:01:03):
Yeah, it was a difficult one.
Speaker 1 (01:01:06):
I suppose even though a precedent has been set like that,
it hasn't opened the floodgates because it was such a
rare combination of circumstances requiely and it's one that yeah,
I won't say sleepless nights, but there was a lot
of thought that went into that, and there was a
lot of counterviews and different things. But the safeguards were
(01:01:27):
put in two and his defense team pushed it as
hard as they could on defending his right to avoid
giving evidence in those circumstances. But look, I feel satisfied
by it. I think the system worked. It was a
different way of approaching the system, but the system worked
in that regards.
Speaker 3 (01:01:47):
And you'd know from your general career as a police
officer too that sometimes for the law to work, you
have to give people who have done bad things and
indemnine tea for the greater good. Yeah, it's a utilitarian concept,
I know. But you know, when I was at the
(01:02:07):
come of DVP, we're quite often we did indemnify people
who would give up major drug importers and so forth.
So you know that was that was the price you
paid for the evidence.
Speaker 1 (01:02:19):
It's a necessary tool, and I break when there's a
different narrative or different discussions on what should be done.
And with the leves and matter I said, okay, well
the option is we don't do that, but we're not
going to find out where Matt's bodies, So.
Speaker 2 (01:02:36):
What are we risking here?
Speaker 1 (01:02:38):
Like it's we ever just just pack up our tools
and go home.
Speaker 3 (01:02:43):
But you're right anyway, Gary, that the floodgates have not opened.
Speaker 2 (01:02:47):
Yeah, well I saw.
Speaker 1 (01:02:49):
I saw that and many a debate and discussion in
parliament with the double jeopardy legislation when that came in,
and that was on the back of the bearable thing.
People we know about it. In summary, if you'd been
acquitted of a crime before the double jeopardy legislation came in,
you couldn't be retried. So again the analogy at the extreme,
(01:03:10):
you could be acquitted of murder, walk out on the
steps of court and say I did it, I got
a way of it, and we couldn't charge that person.
The double jeopardy legislation came in, and there was a
lot of pushback about that. I was involved from the
Bowable point of view, using it sort of as a
test case and the world the sky was.
Speaker 2 (01:03:30):
Going to fall.
Speaker 1 (01:03:31):
The naysayers that didn't want the want this legislation come in.
If this comes in, it's going to turn our legal
justice system upside down. I think to this day the
legislation still hasn't been acted upon, but it's in there
as a safeguard if circumstances happened in bearable so.
Speaker 3 (01:03:49):
And the you would hope would be very careful in
any event. Yeah, you know, you wouldn't want people being
dragged up from years and years and years ago with
some sort of weak evidence. You're right, it has to
be very compelling. Is compelling, it's a very high state.
Speaker 2 (01:04:12):
It's a high high standard.
Speaker 1 (01:04:13):
And look, I understood there was an argument there that
it would allow and it was fresh and compelling evidence,
and it's got to be in the interest of justice,
and it had to be an offense that carries a
minimum of twenty years. There was a lot of things
that went into it, but I understood. One of the
arguments I understood was it would allow police or investigators
(01:04:34):
to do a half hearted job the first time, and
if they lost the trial, I will do it properly
this time. And I could understand that concept that that sloppiness,
but it clearly hasn't come into play. But yeah, they're
interesting thoughts on the way justice can be approached.
Speaker 2 (01:04:52):
When we get back.
Speaker 1 (01:04:53):
We might take a break now, but when we get back,
I want to talk about some of the cases that
you've overseen, some very seen cases and your reflections on
those cases and something that you're very passionate about, and
full credit to you.
Speaker 2 (01:05:08):
I support what you're.
Speaker 1 (01:05:09):
Trying to do in how we could make the crannial
process or the Coroni's court a better place, because I
know you've been doing a lot of work on that
since you've left.
Speaker 3 (01:05:20):
Yeah, I have Okay, great
Speaker 2 (01:05:22):
Okay, we'll be back soon.
The public has had a long held fascination with detectives.
Detective see aside of life the average person is never
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For twenty five of those years I was catching killers.
That's what I did for a living. I was a
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I'm taking the public into the world in which I operated.
(00:23):
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Join me now as I take you into this world. Today,
(00:47):
I had the privilege of sitting down having a chat
with former New South Wales Deputy State Coroner Hugh Dylon.
I say privilege because Hugh shares a passion very much
aligned with what I considered the most important I had
as a homicide detective. That was looking after the families
of people who have died in the tragic, violent and
unusual circumstances, bringing whatever comfort possible to the deceased. Families
(01:11):
by providing answers as to what happened to their loved
ones and where possible prevent unnecessary deaths. Throughout his career,
Hugh presided over more than three hundred inquests, including the
horrific School of Happiness case where one man hunted police
with a crossbow in the middle of the night during
the Hippie festival. He also oversaw murders, suicides, and tragic
(01:35):
accidental deaths.
Speaker 2 (01:36):
As you'll find.
Speaker 1 (01:37):
Out in our discussion, the coroner's court is filled with sadness.
In the motion, Hugh takes us through the cases of
the oversaw, how the system can be improved, and the
personal impact of dealing with death on a daily basis.
Hugh Dylan, thanks for coming on I Catch Killers.
Speaker 3 (01:55):
It's a great pleasure. Gren very nice to see you again.
Speaker 1 (01:57):
Well, it is good to see you, and I always
I had a lot of respect for the role that
you did as a coroner, and you were the deputy
state coroner or is a coroner for nine years. Yes,
that's right, and in prepping for it, I believe that
you oversaw probably three hundred roughly three hundred question.
Speaker 3 (02:17):
Yeah, it's a bit hard to work. It out exactly,
but a round about three hundred, I'd.
Speaker 2 (02:22):
Say, yeah, it's a lot.
Speaker 1 (02:24):
And I don't think people fully appreciate the impact that
the coroner's court has. I found it in all the
areas of policing I work. That's when I saw the
most emotion at coroner's courts, because you're talking about someone's died.
That's generally what the inquest is about. And you've got
the families and loved ones there holding on to hope
(02:47):
or trying to get answers.
Speaker 2 (02:49):
Is that how you felt?
Speaker 3 (02:50):
Yeah, Look, it's a surprising place. It's a surprising niche
in the legal system, and most people in the law,
most people in society have no idea. But I can
remember the first day I went to the coroner's court.
(03:10):
I was a new magistrate and I was really surprised
by it. Apart from anything else. The coroners were doing this,
this kind of work that no other lawyers in our
society do. And also they're working in teams and as
you say, their concern is or who has died, how
(03:36):
they've died, why they've died, but also what can we
say to the families and the families My father was
a coroner's case himself around about forty years ago, and
I remember, I remember very very well getting the news
that he died suddenly, and the shock and the confusion
(04:00):
that that throws you into. So to walk into this
place as a coroner, and to try and grapple with
that confusion, the bewilderment, and of course the sadness was
somewhat bewildering to me as well. But Garry I really
(04:22):
liked being a coroner, and some people would be astonished
to hear me say that, I guess, because of course
you're right. It is a very sad place in lots
of ways. Families are devastated, they're confused, one answers. Sometimes
they have interesting theories about how someone they love has died.
(04:48):
Some of those theories are right, but some of them
are wrong. And it's very difficult to walk people into
the evidence and through it and then bring them to
some sort of understanding, some sense of what happened. I
think some people might call this sense making, you know,
(05:08):
how do we make sense of these terrible events.
Speaker 1 (05:11):
There's a lot of expectation when people get to the
coroner's court. I saw that over the years with families
and it's almost like, Okay, the answer is going to
be forthcoming when the matter gets to the coroner's court,
and I think meeting the family's expectation or that's a
difficult part too, because sometimes the facts don't present the
way the family expected it to, and quite often the
(05:34):
evidence that is given at a coronial inquest is quite
confronting to the families and loved ones of the deceased person.
Speaker 3 (05:42):
Well, that's right, And although you're always very glad as
a coroner if you have found the answers, there are
lots of cases where you don't, and you, as a
homicide or an ex homicide detective, would be very familiar
with some of those cases. You know, there are unsolved
homicides as well as you know all the I want
(06:05):
to call them happy endings, but they're cases in which
there is an answer for people. And to leave people
without answers is it's not only very frustrating, but it's
also very sad because you can't help empathizing and feeling
for them but also with them. You know, if you
(06:27):
lose a daughter, you know, I'm thinking about my daughter
as I'm talking to you about you losing yours. What
a shattering and incomplete kind of sense of life you
might have. So, as I say, sometimes you can provide
(06:47):
answers and that can give people a sense of resolution.
I don't believe there's any such thing as closure. I
think that's a false hope.
Speaker 1 (06:57):
I'm glad you say that, and that tells me you
understand the situation that families go through. And I got
clipped very early in my career when use the word
closure to a family and they pointed out very very
clear to me, it's not the closure. You never get
closure from that. And that's what happens when and it's
not always homicide. If someone's I would find that in
(07:22):
the courrner's court. Those tragic accidents are hard to deal
with too, because I look at homicide and often the
families can allocate blame to a particular person. Where there's
accidents where there's the fault, like there's built up anger
and sadness and that it's nowhere to channel it.
Speaker 3 (07:41):
That's right, and I think the families of missing people
have a particularly onerous load to bear. I guess if
you can bury your your loved ones, you can have
a sense of not camp or anything like that. But
(08:01):
you can say goodbye, but all you have is your
last memories of them, and then they disappear off the
face of the earth. How do you deal with that?
I really don't know, and I never really learned how
to how to give people a sense of peace or
(08:23):
any sense of forward movement. I think the only thing
you can do for people where their loved ones disappear
is respect, recognition. You know, we will do our best
to find out what happened, but sometimes the answer is
(08:43):
beyond reach.
Speaker 2 (08:44):
That's not there.
Speaker 1 (08:45):
I saw with families on missing persons cases quite often
that I felt like it was a step that helped
them in processing what had happened when the coroner would
declare the person deceased. Because what I've seen with families
and friends of people who have just disappeared, they always
hang on to that smidge and of hope that the
person's going to walk through the door one day and
(09:08):
they're going to yell at the person, go what have
you done? And then they're going to give each other
a big cuddle and get on with their lives. So
I think sometimes they hold on to hope, and quite
often I've seen it in cranial inquest where the coroner's
declared the person deceased manner and cause might have known,
but believe that the person is deceased because of checks
(09:29):
that have been done, and I feel like it's a
step forward. But the coroner's court I always found the
expectations were high by the families. It was a lot
of it's built up like if the investigation into the
death of someone hasn't revealed the information or the person responsible.
Quite often the hope is, well, we'll get the answers
(09:50):
at the coroner's court. But that's not always the way,
and that must have carried hard on you being a coroner,
that the family is steering. But where else do we go?
And the sad part is sometimes there is nowhere else
to go after the coroner's court.
Speaker 3 (10:02):
Yeah, and it's very frustrating. And from time to time
I think coroners I think they fail people by not
saying what they really think. Sometimes, I think, and I've
seen this happen, particularly within experienced coroners, they will simply
(10:24):
because they know how sad people are and how hard
it will hit them. If you say I think your
loved one is dead, they say, oh, well, you know
the evidence isn't quite sufficient, so maybe they're still soften that. Yeah,
And I to be honest, I think that does not
(10:47):
help people cope with what has actually happened. If someone
has disappeared and they've I mean very occasionally people do
turn up. I know, we all know that, but it
is so rare. It's just once in many, many blue moons.
And I think as a coroner you have a duty
(11:09):
of care both to the dead in respect to them,
but also to the families to be upfront with families
and say, the investigation has got this far, we don't
know precisely what happened, but your loved one more than
likely is dead. We can't prove it beyond a reasonable doubt,
(11:31):
aps but it's almost certain. So that's all we can do.
Speaker 2 (11:36):
I think.
Speaker 1 (11:36):
I think that's kind of false hope. Can be a
very cruel thing if false hope is offered out. So
I think roll of a coroner and that is quite
often the final step for families trying to find out
what's happened to their loved one, especially with people who disappeared.
Tell us what was your story into becoming a coroner?
Speaker 2 (11:56):
Ah?
Speaker 3 (11:56):
Well, I obviously did a law degree in Australia, coroners
are lawyers. In New South Bales, they're all magistrates. I
did some legal research, I worked for a judge, I
worked for the New South Bale's ombudsman, and then I
got a job as a Comwealth prosecutor. So I worked
for the Commonwealth DPP for a number of years. Then
(12:20):
I was appointed a magistrate. Did about twelve years as
a magistrate and I was on the point of leaving
the magistracy and my friend Mary Durham, who was the
new state coroner, heard that I was contemplating leaving and
she got in touch with me and asked me whether
i'd like to have a go as a coroner. And
(12:44):
to be honest, I thought, oh my god, this is
so depressing, this kind of work. But I really liked Mary,
and she said, well, she said a few flattering things
about me, so I found it out to say no
to her, to be me very forthros, very forthright. She
(13:04):
also is very persuasive, and I thought, okay, well, I've
put off going to the bar for six months, I'll
go and see what this is like. You know, all
experience is good experience, and I really when I got there,
I really liked the work, partly because I was working
(13:25):
with really good people like Mary. But one of the
things i'd really missed as a magistrate was working in
a team. And Gary, you know what it's like working
in teams most homicide cases.
Speaker 2 (13:40):
You share the pressure, so the pressure.
Speaker 3 (13:42):
But it's also sharing ideas and a community, a small community,
a team can generate more ideas than a bunch of
single individuals, definitely, and so strangely enough, although the work
could be very confronting and very sad and saddening, I
(14:08):
really enjoyed working with the team of people I was
working with. So instead of leaving after six months, I
stayed and I just stayed on until basically the chief
magistrate said, well, your time's up. You've had enough time
here and you're coming back to the local court. And
I thought, well, no, I'm not. I like being a coroner.
(14:32):
I don't want to be a magistrate anymore. So that's
when I.
Speaker 2 (14:37):
Left, decide to leave.
Speaker 1 (14:39):
It's funny that you get rotated, or a tap on
the shoulder that you've been there too long. I would
imagine something in the role of a pathway as a coroner,
you'd be learning all the time. Yeah, yeah, you'd be
learning how not just the processes in place, but how
to deal with families and all that. I could imagine
(14:59):
every day you went to work.
Speaker 3 (15:01):
Look, I think that's absolutely right. And I remember saying too,
we had this rotation, three year rotation thing, and I
remember saying to the Chief Magistrate, I don't think I
was any good at this job until I've been in
it for two years, that makes sense. And then so
three years I'm just starting really to get good at it.
(15:25):
And I thought I wasn't an expert coroner until i'd
been doing it for five years. But look, after I left,
I've done further study. I've done a PhD, which is
a study of then you Saitho's coronial system, and I've
learned so much more. So I know that you're absolutely right.
(15:47):
Nine years I was learning all the time, and since
I left the Coroner's Court, I've been learning even more.
So you need to stay in these jobs to get
really good at that.
Speaker 1 (15:57):
Well, it is a specialist field. I would imagine that
the role of a magistrate as compared to the role
of a current is vastly different.
Speaker 3 (16:05):
Very very different. A magistrate's job is primarily running small
summary trials and sentencing. So some days you sit in
a court and sentence people who are pleading guilty to
various things. Other days you have hearings. You might do
bails and apprehended violence applications and that sort of stuff.
(16:31):
After a while, it becomes very repetitious. You'd become to
be perfectly honest, I think I was quite a good magistrate.
But practice makes perfect and you're doing a lot of practice.
So after a couple of years of that, I think
I was pretty pretty good at it. After five years
of it, I really needed a change, and so I
(16:52):
did civil civil cases mainly. And again, it took me
about five years before I thought I was experted that,
and then the coroner's job came on.
Speaker 1 (17:04):
Okay, can you explain what the role of the coroner's
court is? So I obviously aware of it, but if
you could explain to the listeners, because I think there's
a misconception on some of the aspects of coroner's courts
what their role is.
Speaker 3 (17:17):
If you could explain, it's death investigation, So if someone
dies suddenly or in an unexplained or difficult to understand way,
or due to an unnatural cause, accidents, suicide, homicides, these
(17:37):
sort of things in our society, and since the twelfth
century actually there have been coroners who investigated these sudden,
unexplained or unnatural deaths. The coroners are one of the
oldest legal institutions in the world and so Australia imported
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coroners when first Fleet arrived. The first in quest in
Australia was in December seventeen eighty eight a convict diet
and a inquest was held. And so we've had this
two hundred and fifty odd years of people inquiring into
how a death came about. And it's a very different
(18:21):
process from a criminal trial, as you're well aware.
Speaker 1 (18:25):
If you could break that down as well, because I
think people think sometimes it mata goes to the coroner
and the coroner could find this person guilty of in
the fence, but that's not the case at all, and
that's a whole different set of rules.
Speaker 3 (18:36):
Well, even if you think a person is guilty of
criminal offense, you have no jurisdiction to decide that. That
has to be decided elsewhere by that first of all,
by the DPP and then by a criminal court. But
to go back, what's the process. Well, first of all,
I talked about teams. The coroner's seigners work in a system,
(19:01):
a coronial system, and it's a multidisciplinary system. You were
part of it. I was part of it. Forensic pathologists
are part of it. Family counselors, support people, administrators, etc.
Are part of it. But the first thing that happens,
of course, is that someone reports a death, and that's
(19:21):
usually done by police officers. So police might be called
to a hospital because someone's diet of injuries or something
like that. The doctors will report to the police, the
police will report to the coroner, and then there'll be
a medical examination. The coroners and the forensic pathologists will
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decide how to examine the person's body for evidence of
the physiological or the medical cause of death. So that's
the first stage. Of course. Families are notified and there's
a whole process of informing them, which is a shattering event,
(20:06):
as I was talking about a little while ago, really
shattering event for people. So there's a process of talking
family members into this strange process. They may have heard
about or may not have heard about, but most of
(20:27):
them will never have experienced before. So how do you
bring people into that. That's part of it. So we
have a team. We had a team at the Corners
Court family Support team and the forensic pathologists also had
social workers who are dealing with families. Then we have
(20:49):
police involved. If the circumstances of a case look like
they're unnatural, if the cause of death is looks like
it's unnatural, then the police will do an investigation on
behalf of the coroners. Sometimes that will look like a
homicide investigation, and if it is a homicide, it'll be
(21:10):
a very very thorough investigation. If it's an accident, there
will also be a police investigation. There may be other
experts called in aviation experts or all sorts of people.
If someone takes their own life, there will also be
a police investigation, and that will be somewhat different from
(21:32):
a homicide investigation because clearly, not only has a person
whom other people love died taken their own life or
apparently so, the family will be so psychologically shaken by
this that they need real care. And that's difficult because
(21:56):
the first responders will usually be young. Police office is
followed by detectives. The detectives are usually much more experienced
and have seen terrible things usually, but there are lots
of things going on in those scenarios, the shattered love relatives,
(22:21):
but also what happens to the young police officers who
are possibly seeing these sort of scenarios for the first
time in their lives.
Speaker 1 (22:31):
Yeah, you mentioned you mentioned the police and what we'll
talk further about that later on, but the impact of
police because we mentioned at the start the full range
of emotions and the heavy emotional toll inquest take. But
there's a lot of people that are affected by it.
On the issue of suicides too, they're difficult ones. And
(22:51):
I know from earlier because quite often the family don't
want to accept that someone's taken their own life, so
their minds.
Speaker 2 (22:59):
Sticking over it.
Speaker 1 (23:00):
You know, there must be something more to this, so
you're dealing with that aspect of it as well.
Speaker 2 (23:05):
But yeah, it's.
Speaker 1 (23:07):
Confronting the whole range of things. And then accidents. The
purpose of investigating an accident is to find out ways
of preventing that accident from occurring. Again, that's something that
the coronial process is involved in as well.
Speaker 3 (23:23):
That's rightight, And although I think we do that quite
well in in a lot of cases we only hold
about it one hundred inquests a year in the South Bales,
but there are eight thousand or roughly eight thousand deaths
reported every year, so and around about forty percent of
(23:43):
the reported deaths to unnatural causes. So we don't really
investigate enough enough accidents, I think to learn all the
lessons that could be learned. Ideally, a cronial system should
really thoroughly investigate all the accidents that occurred, that fatalities
(24:10):
and try and put them into patterns or identify trends
so that we can we can pull out life saving lessons.
One thing that people don't often think about, and frankly
I didn't think about when I was a coroner, but
I have thought about since is the economic value of
(24:30):
a human life. The Australian government puts an economic value
on an Australian life. It's called the value of a
statistical life, and that in twenty twenty four it was
estimated to be five point seven million dollars and a
(24:50):
life year is valued by actuaries at around about two
hundred and forty or two hundred and fifty thousand dollars.
So investigating thoroughly the causes of accidents should be regarded
as an investment in life saving because if we could
(25:12):
save more lives, if we could prevent more accidents, then
it would be obviously good for the families and the
community in general if this human cost wasn't spent or incurred.
But there's also a value to the economy. So if
(25:33):
you think about it, three thousand unnatural deaths a year,
that's possibly fifteen billion dollars just putting it in dollar terms,
which is a very crude an unsatisfactory way to put it,
but it's really worth looking at. This is not just
(25:54):
a lot of grief and a lot of sadness. It's
an enormous cost to the society that we live.
Speaker 1 (26:01):
In that we've lost the life these things like I'll
pluck this as an example because it's fairly topical at
the moment or current, like eese scooters, when there's a
death on an new scooter, we see that these scooters
on long foot paths, or the role of a coronario
would imagine I'm talking hypothetically here, is if there's a
(26:23):
series of accidents in quests, Okay, well how did this accident?
There might be recommendations like the helmet recommendation there is
an obvious one or not the right on footpaths or
certain things that might prevent deaths as well.
Speaker 2 (26:35):
That's the role of a corona.
Speaker 3 (26:38):
Yeah, and ideally most in quests would result in recommendations
to public health and safety officials who would then work
through the practicalities of their I mean coroners are not
engineers or those sort of things. But a good in
quest should bring in experts, experts, that's right. And then
(27:04):
and very often families also have good ideas about how
to because they've given a lot of thought to how
their loved ones have died. They often have good ideas.
So in New South Wales, if we could increase the
number of cases in which recommendations were produced, or if
(27:24):
we could identify more patterns and trends of fatalities and
serious injury, then we would have a more effective and
more productive coronial system than we have at the moment.
Speaker 1 (27:38):
Is there any accident you've seen that's really stuck in
your mind?
Speaker 3 (27:43):
Well, one of them is a terrible collision on Sydney
Harbor which I spent some weeks inquiring into. Yeah, that
was very very interesting.
Speaker 1 (27:58):
Is that the one where for people were killed.
Speaker 3 (28:02):
Four people were killed. There were passengers on board a
pleasure cruiser which was proceeding from west towards towards Circular Key,
and a river cat ferry came out of Circular Key.
It was on its way back to the Balmain dockyard.
(28:24):
Were at Birthed Yep and right under the harbor bridge
on the on the southern side. The boat was run
over by the by the ferry.
Speaker 1 (28:36):
How many people were on the boat, I can't quite remember.
Speaker 3 (28:39):
I think it was around about nine people.
Speaker 2 (28:41):
Right, and four.
Speaker 3 (28:42):
People were killed.
Speaker 1 (28:43):
Yeah, what was it about that stuck in your mind,
that that particular matter.
Speaker 3 (28:50):
Well, there were a number of things. Really. My council
assistant and I and my team went out on Sydney
Harbor and you know, it took a view as it were,
and we went up that the river with you know,
in a ferry in a river cat. The father of
a young dancer who was killed was representing his family.
(29:15):
He didn't have a lawyer and he was on the
he was on the ferry trying to talk to me.
And one of the one of the difficulties you have
if you're a coroner, as you you can't really talk
to the lawyers and the families in the course of
either taking a view or taking evidence of that sort
(29:35):
of thing. And I could see this poor man really
trying to understand what the hell are these lawyers up to?
You know, why can't I talk to the coroner? And
my council assistant was trying to say, look, the coroner
is very, very interested in what you've got to say,
but we've got certain rules about all of this sort
(29:57):
of stuff.
Speaker 2 (29:58):
So that was one thing just on that.
Speaker 1 (30:02):
It's difficult, isn't it, Because I know I've seen at
scenes and locations circumstances like that, and the coroner's there
and you've got the families there or the people that
have a vested interest in the situation. Obviously they want
to speak to speak to the coroner, but you can't.
You've got to have that independence that you're not speaking
(30:22):
to them directly or on specifics of the evidence.
Speaker 2 (30:24):
Yeah.
Speaker 3 (30:25):
Actually, since I've finished as a coroner, I've given more
thought to this, and I wonder whether sometimes coroners might
not be better off at least having a meeting with
the family with representatives or you know, someone to ensure
that you don't make any false promises or cuddle up
(30:49):
if you like, become biased towards families. But I wonder
sometimes whether we could do more to show the family
is that we actually care about them as well as
care about finding out what the answer to the question
about how their loved ones died.
Speaker 2 (31:10):
It carries a lot, doesn't it.
Speaker 1 (31:12):
If the families know that you care, whether that's a
police officer or a coroner, a legal person or anyone
that gets caught up in these situations. If there's you're
showing that you care, that can help the family so much.
Speaker 3 (31:25):
Well, I think so, And sometimes not always, but sometimes
after an inquest I would step down from the bench
and I talk to the family. That's after I've given
the decision. And I remember a particular case, I was
doing an inquiry into an inquest into a murder suicide case.
(31:48):
A father who had separated from his wife had taken
his three children off in a car and put a
I won't describe what happened, but anyway, he killed himself
and the three kids. The mother came to the court
and this was I think three years after the murder suicide,
(32:15):
and she was pregnant. She had repartnered since and after that,
and she spoke about how much she missed her children,
and so on and so forth, and I just admired
this woman so much, her courage in not only putting
up with what had happened. And as I said, I
(32:35):
don't think there's any such scene as closure. That she'd
managed somehow to face the world and go forward, and
now she'd repartnered, and now she was bringing new life
into the world. And I just thought, respect, and I
spoke to her and I said, how do you do this?
(32:58):
And she said, look, I'm not going to let this
guy get away with killing my kids. I'm not going
to be crushed by it. I'm not going to allow
him to destroy the life that I had. I'm going
to give new life. And I just thought, Wow, she's amazing.
(33:21):
And very often I saw things like that happen in court.
Speaker 1 (33:26):
I'm sure you took strength and the inspiration from the
way some of the families conduct themselves. So that's what
I saw, and I thought where I would often think,
where do you get that strength, whether you get that
strength to carry on? And also they can even see
joy in life, like the ability to get through as
you just described with the mother there, that she's going
(33:49):
to live a life despite what's happened.
Speaker 2 (33:51):
That's right.
Speaker 3 (33:51):
And some people are obviously very angry and they never
really get over their anger. But some people can be
remarkably forgiving. People can make mistakes, and sometimes those mistakes
cause deaths by a mission or commission. So sometimes you know,
(34:13):
for example, nurses or doctors miss clues. Let's suggest a
child is very, very sick and needs some sort of
virgent intervention, and by the time there is an intervention,
it's too late. I remember a case involving a little
boy who died and he'd been seen by well by
(34:37):
the time he died, he had been seen by six doctors.
The last two doctors realized what was happening and tried
to give emergent care, but the four previous doctors thought
he was sick but had a flu or some sort
of viral thing, but he'd get over it anyway. In
(34:58):
the inquest, some of the medical and health practitioners, once
they had finished their evidence, turned and faced the family
and said how sorry they were. But there was one doctor,
young doctor, and I still feel quite sorry for her,
but she couldn't bring herself to apologize. And I don't
(35:20):
know why not, but I really feel that she lost
an opportunity because the family were very willing to forgive
all these other people who did apologize, and I just thought, gosh,
if you turned and said you were sorry, that this
(35:41):
had really affected you as well. And I'm sure she
was affected, but maybe she got legal advised. You know,
I don't speak. Who knows. Maybe she just couldn't bring
herself to say anything. But I just thought, if you
could turn around and talk to them, I think it
would make both of you, the family and this doctor
(36:05):
so much happier than they were.
Speaker 1 (36:09):
I think you've just encapsulated when they talk about the
emotion that comes in the corner's court, just with that
one story that's on the thing that lives are shattered,
and it's about how people move forward. But I think
you might be right, And yeah, saying sorry can often
be the thing that helps people move forward.
Speaker 3 (36:29):
Can I tell you another story ago?
Speaker 2 (36:30):
Yeah?
Speaker 3 (36:31):
Yeah, this one had a happier ending. Really a young woman,
she was nineteen years old. She got very sick. She
was working on a sharing team somewhere in the southwest
of New South Wales and it looked like she had
a flu. So her boyfriend, who was on the team said,
(36:51):
go to bed. The sharing team boss was this marry guy.
Little murry guy said, going like and she just got
sicker and sicker though, and at some point in one
of the breaks, her boyfriend went in and saw him
and thought, oh my god, she's really sick. So they
(37:12):
called an ambulance, but it took nearly an hour for
the ambulance to get there. It was way out somewhere.
They got it to the hospital, but she was very,
very sick, and despite getting urgent attention, she died. We
held an inquest because one of the difficulties was there
(37:32):
wasn't a clear diagnosis of what was killing her, and
we still don't really have an absolute diagnosis actually, but
in any event, we held the inquest and her father,
who was a Victorian farmer, very big man, six foot
four or something, came in and we went through the evidence.
(37:57):
The family was represented by a very good arrister from Victoria,
and I had a very good counsel assistant. You may
know her, Peggy dwy a Silk or so. It's the Victorian.
And one of the great things about this inquest I
thought was that there was no bitterness, and at the
(38:22):
end of the case, I gave my decision and my reasons,
and I explained how you know, what had happened, and
as best we could what the diagnosis we thought was
most likely to be. Give my decision. I walk off
the bench. I'm sitting in my chambers, and Peggy comes
out and says, Hugh, he come to the come to
(38:45):
the door of the court. So I got up and
I went to the door of the court and we
pulled it out in a little bit and there was
this enormous Victorian farmer with his arms around the little
Marory shearing boss, both in tears, both embracing, and both
so sad, but so happy to have this moment with
(39:10):
one another. They were both they both loved this girl, the.
Speaker 2 (39:17):
Mary.
Speaker 3 (39:18):
Boss was so devastated by her death. I mean when
he gave evidence, he was just weeping, pouring tears pouring
out of him, very very emotional, as was her dad.
And so there was this moment of cathasis. It doesn't
always happened some you know, some people walk away still
(39:40):
feeling angry or whatever. But this was one of those
moments where thought, today we did something good. And having
spent a lot of time in criminal courts, I can say,
I don't think on a lot of days I ever
walked out of a criminal court thinking today we did
something good.
Speaker 1 (39:58):
Well, yeah, there's not not many people walk out happy
out of the criminal court. That if the person's convicted,
he or she's angry. If the person gets off, that's
the police or the prosecution angry.
Speaker 2 (40:11):
But the way you've.
Speaker 1 (40:12):
Described that, I can picture it, and that is doing
something good, like.
Speaker 2 (40:17):
True.
Speaker 3 (40:17):
And it was a moment of grace really, you know,
there's there's very generous hearted men were embracing each other
and owning the loss that they both felt.
Speaker 1 (40:33):
Yeah, and you could imagine the types that you're describing,
they could bottle it up. But the fact that they
let the emotion go, and you see that quite often
in the coroner's court. It is it is that emotional place.
The breakdown of the adversarial system for the criminal courts
and inquisitorial for the inquest. What's the difference in the
(40:54):
way that evidence is allowed into those courts.
Speaker 3 (40:57):
Well, the two things rely on different ways of thinking.
So in a criminal trial, one party the prosecutions as
a theory a hypothesis. The hypothesis is you Gary have
murdered me Hugh, you deny that allegation, and either prosecutor
(41:25):
have to try to prove my hypothesis. And I do
that by producing proof which I hope will satisfy people
in the jury beyond a resumal doubt that this is
the only reasonable answer you could come up with. That's
deductive thinking. The other way of thinking is inductive thinking,
(41:47):
which is to say, we look at all this evidence,
which may be scattered and fragmented in different ways, and
we try and come up with a theory. What theory
may sense of all this stuff that we have collected.
So that's theory building or inductive thinking. Now, of course
(42:12):
the adversarial side. There is an adversarial side to inquest
and you've experienced that, and that's where people who have
a different theory or have a particular theory challenge the
range of theories that have been developed. So current might thinking, okay, well,
the possibilities available for me are suicide, homicide, jumped off
(42:40):
a cliff, fell off a cliff, accidentally, was kidding up
by by by martians and assaulted who knows what. So
there might be a range of possible theories, and some
of the people who have an interest in this it
might be police, or it might be persons of interest
(43:01):
as we call suspects might want to challenge some of
these theories because they don't want the coroner to ultimately
settle on a particular theory that blames them. So there
is a degree of adversarialism in it in it or
(43:21):
can be in an inquest. But it's all about really
this inductive thinking. What is the most satisfactory theory we
can come up with that explains this death and the
circumstances that surrounded it, And that means you have to
look as carefully as you can at the surrounding circumstances,
(43:44):
and that might mean that you take a wide look.
Speaker 1 (43:47):
Does that allow for opinions to come in? Yes, because
rare in the criminal court that you get off your opinion,
but in the coroner's court, quite often opinions the coroner
takes that account.
Speaker 3 (44:00):
Opinions can be very important and they can be quite persuasive.
And also hearsay evidence. So here's some heresay evidence. Obviously
can get into a criminal trial, but only under very
limited circumstances because there are questions about the reliability of
(44:20):
hearsay and of opinions. Juries have to come up with
their own opinion about whether someone's guilty or not. That's
the idea about opinion evidence unless it relates to some
sort of area of X that's beyond common knowledge, etc.
But coroners are running an inquiry, not a trial, and
(44:44):
that's the fundamental difference. And that's what I'm saying inductive thinking,
that's I'm thinking about, what's the question, How do I
answer the question? What's the theory I can come up
with that answer answers the question question is how did
this person die? How did this death come about? What
(45:05):
explains it? But if we go to a trial, the
prosecution thinks it knows the answer to that, then it's
got to persuade a jury to agree with that answer.
Speaker 1 (45:18):
I'm just reflecting back on my first experience at an inquest,
and I think it was even in my uniform days,
where a young child, the mother was in the bathroom
and the hair dry fell into the bath. The two
kids in the bath just toddlers, and one died and
one survived from that. And I remember, and this was
(45:42):
probably the first sort of situation I've been to like
that where a brief had to be put together for
the coroner, So we put together a coronial brief. A
lot of questions were asked by what sort of system
did they have in the fuse box with the electrical work,
wasn't the safety Why didn't the circuit break a trip
at the time, and think like that long time ago.
But I think some recommendations came on the back of that.
(46:05):
That's the type of incident that would be bought before
the coroner.
Speaker 3 (46:10):
Yeah, definitely, And it's the very kind of incident that
should be brought before the coroner because there's obviously if
you explore that scenario thoroughly enough, there are there's real
potential for saving life in future.
Speaker 1 (46:28):
And warning's about electrical appliances near the bath and where
powerpoints are located near the bath.
Speaker 3 (46:34):
All of that, and yeah, well I would imagine a
good coroner came up with a number of recommendations, and
no doubt the police, which might have been you Gary,
contributed to that thinking process.
Speaker 1 (46:49):
It was I remember it because it was such a tragic,
tragic accident, and that's what it was.
Speaker 2 (46:55):
It was an accident.
Speaker 1 (46:56):
But whether the accident could have been safeguarded against by
you know, putting things in place or just letting people
be more aware of the situation. Another one, and I'm
just reflecting on all the different experiences I've had in
a coroner's court. The bower of all matter, you're familiar
with it, and people that have listened to the podcast
would be familiar with it. The murder of Evelyn green Up,
(47:19):
Colin Walker, and Clinton Speedy in nineteen ninety and ninety one.
Over a five month period, a person had been a
charge with one of the murders, went to court and
the person was acquitted. I became involved in a reinvestigation
and we just saw that we reinvestigated. We thought we
(47:40):
had enough information for the matter to go back before
the courts for the other two because the double jeopardy
legislation wasn't in on the other two matters that a
person hadn't been charged with, but the DPP knocked it back.
We then went to an inquest and had an inquest
where it was the first time witnesses in regards to
all three matters had provided any form of evidence in
(48:02):
a court environment because the person that was charged with
that crime was only dealt with the facts relating to
the murder of Clinton Speedy. We've gone to the inquest.
The inquest ran over a number of weeks. Everyone gave
evidence and there was opportunities for people to be cross examined.
(48:24):
On the back of that, I think it was John Abernathy,
was a coroner at the time, made a recommendation to
the DPP that he has reasonable cause that the known
persons involved in the matter and that all three matters
should be looked together. On the back of that, the
DPP then a little bit down the track, but the
weight that was carried from the inquest and John Abernathy's
(48:48):
recommendations decided to exo fishao, indict diet the person. I
raise that as an example because that's where I see
the coronial court working in an investigation. In that gave
the witnesses the opportunity to give evidence in a court
room environment, and then an assessment could have been was
made on the weight that could be placed on the evidence.
(49:10):
Is that how you see a coroner's court can be used. Yeah.
Speaker 3 (49:13):
And in fact, in New South Wales, if a person
has died and homicide is the suspected cause of that
and death and inquest is mandatory and so yeah, I
was thinking about this the other day. I'm quite sure
how many homicide inquests I did. It's probably I would
(49:36):
say probably twenty CYCA. In some cases I did refer
cases to the DPP. In other cases we didn't get
far enough. And in fact, the very last case I
did as a coroner was in Newcastle. It was a
double murder and we we had a person of interest
(50:02):
who gave evidence, but there simply wasn't enough evidence in
my opinion, the opinion of my counsel assisting or the
police investigators to refer to the DPP. An interesting, very
interesting case. Yeah, And you know, you never know. Sometimes
(50:25):
people say things or do things which pushes a case
where the DPP has doubts that the evidence is sufficient
over the line. And so a couple of a couple
of times I referred cases to the DPP after they
had initially decided there wasn't enough evidence. And sometimes they
(50:51):
put people on trial, sometimes they don't. Sometimes they take it.
You know, once they have a look at all the evidence,
they think, ye, that will work or not work.
Speaker 1 (51:01):
And I think that's what perhaps the public caren't fully
informed on that when the coroner maker makes a recommendation,
it's still that's not the end of the story. That
doesn't mean the person's going to trial. The DPP's got
to assess it from a criminal point of view, whether
there's sufficient evidence to warrant charges.
Speaker 2 (51:21):
Against a person.
Speaker 1 (51:22):
I suppose I lost my faith and I'm sorry to
say this when you're seeing here as a coroner, very
early in my career, but got it back. Naive young
detective working on a case. It was a brutal case.
A person had been shot with a shotgun and dumped
in the boot of his car, and his car was abandoned.
(51:43):
Locals called the police out. It was a horrendous, horrendous scene.
It was during the heat wave and the deceased body
was in the back of the boot for five days.
I remember the case well, I remember the post mortem.
It was a horrendous situation. There was what I considered
evidence a person person of interest. We won't mention the
names or the case. Young detective thinking, this is frustrating.
(52:07):
We know this person has done it, and it was
sort of suggested, let's take the matter to the coroner
and maybe further evidence will be forthcoming. What and I
knew this was a possibility, but it shocked me when
I saw it actually work. In the process, the person
of interest got in the witness box. We had presented
(52:28):
the brief to the coroner. I was excited as a
naive young detective, thinking, Okay, well this is We're going
to watch this person get carved up. He got in
the witness box and he was said, I declined to
answer any questions on the ground I might incriminate myself.
He got thanked by the coroner and left the court,
and it was sort of my expectations were high, the
(52:48):
family's expectations were. My expectations were high because I was
naive as the workings of the court. But I thought
there I just lost a little bit of faith in
that that write the silence. I fully understand the concept
of the silence, but a coronial inquest is to find
out what's happened to a person, and this person clearly
(53:09):
had relevant information about about how this person died, but
was allowed to just say I'm not going to say anything.
Speaker 2 (53:18):
What's your thoughts on that?
Speaker 3 (53:19):
I have mixed feelings about that from a purely coronial
point of view, Like everybody else, I would like to
hear the story from the person who probably knows most
about it. On the other hand, if there is a
strong case against a known person, I'd be quite reluctant
(53:42):
to force them to give evidence. The reason being that
if you force them to give evidence, they object, and
then you say no, no, no, you're going to give evidence.
They have to give evidence, and then they talk, but
whatever they say can be used, and it can't be
used in any way at all. So you can't be
(54:06):
used directly against them or indirectly against them, which is
even worse. So if you force someone to speak, my
view was that you run the real risk of jeopardizing
what may be a strong case at trial, because they'll
be able to say, oh, well, the cops went and
(54:28):
got this evidence.
Speaker 1 (54:30):
It's not just the evidence that provided can't be used.
It's a flow on, that's right.
Speaker 3 (54:35):
All the evidence that is obtained indirectly as a result
of them speaking is inadmissible.
Speaker 1 (54:42):
Well, I'm sure you are for me with the Matthew
Levison cases and that was an interesting I found that
an interesting case for a whole range of reasons. But basically,
and we've had Mark and Faye on the podcast, so
people have probably heard talk about the situation. Matthew disappeared.
(55:04):
He'd been out Saturday night at Oxford Street in Sydney
with his partner and disappeared. The partner was eventually circumstances
around the disappearance was a bit strange. They've waken up
and that Matthew's gone and the partner got on with
his life. And then Mark and fayr initi when they
(55:25):
were contacted by Matthew's employer he hadn't turned up for work.
They went to the police and reported that Matthew missing.
There was an investigation and I can say the name
that he hasn't been convicted of the murder, but it's
all public record. Michael Atkins, he's partner at the time,
was charged with murder. A murder trial was conducted, and
(55:46):
we should note that Michael Atkins was acquitted of murder
and manslaughter in two thousand and nine. So Mark and
Fayer left in and I'm sure you'd understand the situation.
Left in this horrible situation where they've okay, they've put
their faith in the justice system, it's gone the court
and then what have we got. Well, we've got no
answers because we've been told that this person wasn't responsible
(56:08):
for son's son's murder by the court during the trial
I became involved in it. They spoke to me and
we looked at okay, we could go to a cranial
inquest because and I think the representations they made to
the coroner were we put our faith in the justice
system as in the court system. We still don't have
(56:29):
answers for our son. Can we have a corannial inquest?
And on the back of that, there was a decision
that an inquest would be held. There was a lot
of layers to it, but it got to the point
where I was satisfied from a homicide to take this
point of view that we'd taken the investigation as far
as we possibly could. There was not going to We'd
(56:51):
gathered all the evidence of available evidence, so there wasn't
an opportunity because double jeopardy legislation had come in by
that stage. There wasn't going to be an opportunity to
reach uge because we hadn't gathered fresh and compelling evidence.
So then a bit of a conundrum. And you know,
Mark and Fay would on weekends go look for Matt's body.
They were desperate to get Matt's body back. And I
(57:12):
still remember having the conversation with them about what do
you hope to achieve from the inquest? And I think
it was Elaine Truscott was the coroner and very very
considerate of everyone's feelings and the appropriateness of the whole
way the matter has been run. And the decision was
made to give Michael Atkins a Section sixty one certificate
(57:35):
so that he could and when the listeners hear this,
they think this is ridiculous. But he could have got
in the witness box and said, yes, I murdered Matthew
Levison and this is how I did it, and that
we couldn't use that evidence.
Speaker 2 (57:48):
But that's the.
Speaker 1 (57:49):
Deal that we made a lot of processes that we
had to go through to do that, and it was
contested at court and Michael Atkins's defense were doing a
great job in protecting them. Eventually a decision was made
that he could give evidence with a section sixty one certificate.
He purjured himself whilst giving evidence in the witness box
(58:10):
for a week trying to answer questions and dodge around,
and then he was given the indemnity from the Attorney
General if he took us to Matthew Levison's body, which
he did. That's using an inquest in a way that
I don't think those said the circumstances would present themselves
very often. I know there was some sort of pushback
(58:32):
on people thinking, oh, well, are we really usurping the
person's right to silence? To me, I felt that it
was the right thing to do. I think Mark and
Fay have got their son's remains back. No one's been
charged with the murder. I'm just interested in to getting
your thoughts because I know it caused some different opinions.
(58:52):
I won't say controversy. Everyone wanted to see it resolved
in some way. What's your feelings on that?
Speaker 3 (58:59):
Yeah, well, and I've talked to various people about this.
Some people I know and respect, some lawyers I know
and respect very much don't like it at all, for
the very reasons you've just explained that it seems to
run against the ethos of our criminal justice system. On
(59:23):
the other hand, I couldn't help feeling for the Leveson
family to be honest, to get their son's body back,
to be able to bury him, to at least get
some idea of what actually happened to him. I think
was worth the cost. In that particular case. There's are
(59:48):
very rare circumstances, and I don't think the principle that
people are concerned about of protecting people's right to silence
is in any way undermined, and in fact, in some
ways it's strengthened, I suppose, because it's shown that if
(01:00:09):
you if you force someone to speak against the against
their own interests, to tell the truth, in other words,
then there is a price to pay for that. And
you know, when you when you go back and think
about the right to silence, it goes back to the
days when if you were found guilty of an offense,
(01:00:31):
you were hung for it. So obviously there had to
be some protection against people being hung on the evidence
that came out of their own mouths. You know, that's
torturing people, really, one way or the other. So I
fully support the right to silence, and you know, would
always do that, but I think in this particular case,
(01:00:54):
and I really respect Elane, trust God as well as
a human being, as well as as well as a coroner,
I think she made the right decision.
Speaker 2 (01:01:03):
Yeah, it was a difficult one.
Speaker 1 (01:01:06):
I suppose even though a precedent has been set like that,
it hasn't opened the floodgates because it was such a
rare combination of circumstances requiely and it's one that yeah,
I won't say sleepless nights, but there was a lot
of thought that went into that, and there was a
lot of counterviews and different things. But the safeguards were
(01:01:27):
put in two and his defense team pushed it as
hard as they could on defending his right to avoid
giving evidence in those circumstances. But look, I feel satisfied
by it. I think the system worked. It was a
different way of approaching the system, but the system worked
in that regards.
Speaker 3 (01:01:47):
And you'd know from your general career as a police
officer too that sometimes for the law to work, you
have to give people who have done bad things and
indemnine tea for the greater good. Yeah, it's a utilitarian concept,
I know. But you know, when I was at the
(01:02:07):
come of DVP, we're quite often we did indemnify people
who would give up major drug importers and so forth.
So you know that was that was the price you
paid for the evidence.
Speaker 1 (01:02:19):
It's a necessary tool, and I break when there's a
different narrative or different discussions on what should be done.
And with the leves and matter I said, okay, well
the option is we don't do that, but we're not
going to find out where Matt's bodies, So.
Speaker 2 (01:02:36):
What are we risking here?
Speaker 1 (01:02:38):
Like it's we ever just just pack up our tools
and go home.
Speaker 3 (01:02:43):
But you're right anyway, Gary, that the floodgates have not opened.
Speaker 2 (01:02:47):
Yeah, well I saw.
Speaker 1 (01:02:49):
I saw that and many a debate and discussion in
parliament with the double jeopardy legislation when that came in,
and that was on the back of the bearable thing.
People we know about it. In summary, if you'd been
acquitted of a crime before the double jeopardy legislation came in,
you couldn't be retried. So again the analogy at the extreme,
(01:03:10):
you could be acquitted of murder, walk out on the
steps of court and say I did it, I got
a way of it, and we couldn't charge that person.
The double jeopardy legislation came in, and there was a
lot of pushback about that. I was involved from the
Bowable point of view, using it sort of as a
test case and the world the sky was.
Speaker 2 (01:03:30):
Going to fall.
Speaker 1 (01:03:31):
The naysayers that didn't want the want this legislation come in.
If this comes in, it's going to turn our legal
justice system upside down. I think to this day the
legislation still hasn't been acted upon, but it's in there
as a safeguard if circumstances happened in bearable so.
Speaker 3 (01:03:49):
And the you would hope would be very careful in
any event. Yeah, you know, you wouldn't want people being
dragged up from years and years and years ago with
some sort of weak evidence. You're right, it has to
be very compelling. Is compelling, it's a very high state.
Speaker 2 (01:04:12):
It's a high high standard.
Speaker 1 (01:04:13):
And look, I understood there was an argument there that
it would allow and it was fresh and compelling evidence,
and it's got to be in the interest of justice,
and it had to be an offense that carries a
minimum of twenty years. There was a lot of things
that went into it, but I understood. One of the
arguments I understood was it would allow police or investigators
(01:04:34):
to do a half hearted job the first time, and
if they lost the trial, I will do it properly
this time. And I could understand that concept that that sloppiness,
but it clearly hasn't come into play. But yeah, they're
interesting thoughts on the way justice can be approached.
Speaker 2 (01:04:52):
When we get back.
Speaker 1 (01:04:53):
We might take a break now, but when we get back,
I want to talk about some of the cases that
you've overseen, some very seen cases and your reflections on
those cases and something that you're very passionate about, and
full credit to you.
Speaker 2 (01:05:08):
I support what you're.
Speaker 1 (01:05:09):
Trying to do in how we could make the crannial
process or the Coroni's court a better place, because I
know you've been doing a lot of work on that
since you've left.
Speaker 3 (01:05:20):
Yeah, I have Okay, great
Speaker 2 (01:05:22):
Okay, we'll be back soon.
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