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Inquiry into matters arising from the post mortem and anatomical examination practices of the Institute of Forensic Medicine commonly referred to as the Glebe Mortuary

Report to the Governor, Sydney, 6 August 2001 Pursuant to Letter Patent
21 March and 14 June 2001 by Bret Walker SC

[The following information has been edited from the report by Dr Robert N Moles]

The Commission of Inquiry was to determine if the Glebe Mortuary under the directorship of Associate Professor John Hilton had engaged in any practices of removing tissue from deceased bodies, using such tissue or treating such bodies in contravention of the following legislation:

Human Tissue Act 1983
The Anatomy Act 1977
Coroners Act 1980

It was also to inquire into any possible unethical practices. The Sunday Program on the Nine Network on 18 March 2001 led to the announcement of this inquiry by the Minister on 19 March 2001. The report said that the public discussion in the media was directly relevant to the assessment of public sentiment in relation to the ethical issues involved.

The main issue to be addressed was the possible removal of organs (mostly brains) without the informed consent of relatives and other related

The report stated that the Crimes Act 1900 and the Public Health Act 1991 were statutes that every professional must observe as being relevant to issues of ethical conduct. Each of the above three Acts are intended to promote the public interest. It was noted that the Coronial function was not to pursue medical or epidemiologic research, but to establish the cause of death in a particular case. It that can be done satisfactorily without a post-mortem (because the cause of death is already obvious) or without holding an inquest, then those procedures may be unnecessary.

The report discusses the difference between hospital autopsies and coronial autopsies. The former may be conducted for teaching, research or to confirm diagnoses, obviously, subject to appropriate consents being obtained. The latter is to establish the cause and manner of death where that is unknown, or the identity of the deceased if that is not known. The Coroner’s Act does not authorise the removal or use of tissues from a dead body for any purpose other than the establishment of the cause and manner of death.

Whilst the Tissue Act may allow the removal of tissues for other socially beneficial or therapeutic purposes, this does not extend to tissues removed as a result of coronial authorisation. Use of body parts or tissue, other than in accordance with the relevant statutes would constitute an offence.

This being so, the removal of body parts from coronial cases where the removal was solely for research purposes – in the sense that the parts would not have been removed in order to investigate the manner and cause of death of those persons – constitutes a criminal offence.

Some bodies used here were donated under the Anatomy Act 1977.However, the wording of the Act means that such work must be limited to dissection for the purposes of understanding anatomy, being the structure and relationships of the various parts to each other. This the infliction of trauma to a dead body is not “anatomical examination”.

The report noted that records of inspection, where made under the Anatomy Act should have been made, and if made should have been kept, and if kept should have been retrievable.

It is a shortcoming in the Department of Health that one or more of these trite requirements for good administration should have been neglected.

The report said that the issue to be considered was improperly interfering with a dead body or offering any indignity to any dead body or remains. This must connote some interference not authorised by law, and is not done in the bona fide belief that it was so authorised or some justifiable purpose. Any Acts done in ignorance of the provisions of the Crimes Act, were committed by the staff acting in good faith.

Long bones and joints

One class of cases involved allegations about the wrongful removal or use of such items.

The inference was that in each of the 42 cases looked at here the parts were removed for medical research and not for the purpose of ascertaining the manner and cause of death.

Only Dr Cala, one of the pathologists on the Institute’s staff appeared to contest this inference.

Every other pathologist interviewed in relation to this matter had agreed that that had in fact occurred. In the cases mentioned, bones were removed for orthopaedic research when not related to the apparent cause of death. The inclusion of the subsequent findings’ inclusion in the post mortem report did not mean that they were related to the manner and cause of death. All pathologists other than Dr Cala accepted this was the case.

The one exception was Dr Cala who in interview said things I think are likely mistaken about some of these cases where he was the responsible pathologist.

He doubted that the specimens were removed from the bodies rather than inspected in situ. The researchers themselves had no such doubts. Dr Cala thought that he had commissioned specialists to conduct such examinations in road traffic cases although there was no obvious pattern of such requests. He thought he had seen the specialist’s reports whilst compiling his own report, but there is no reflection of the outside specialists’ reports in his own reports,
“… a remarkable omission given his acceptance of the usual and proper approach noted in 95 above”.

Dr Cala’s written notes to the inquiry stated that their removal was purely for research purposes. Bret Walker SC was satisfied that the Cala cases were not exceptions to the findings in the other cases. It seems that Dr Cala thought that removal for research purposes if done in accordance with arrangements put in place by the Director was permissible. These were cases of an unlawful offence under the provisions of the Tissue Act. The time for prosecutions has run out long ago, and it may not have been in the public interest for such prosecutions to take place. The cases do not warrant the sternness of saying that those involved conducted criminal offences. The widespread ignorance of the law under which they took place should be attributed to a systemic failure by the profession in its education and training and a deficiency in the procedures for the obtaining of medical research.

The social value of the research does not affect the unlawfulness of the process involved. Professor Hilton was sincerely of the view that certain aspects of medical research were justified as part of the post mortem examination. Bret Walker SC said he was not convinced of the correctness of that view. Some statements of policy by the RCPA were either incomplete or misleading.

Hammer blow to the head

In 1996, it was necessary to determine if a person had died as a result of a hammer blow to the head. Dr Cala conducted an experiment which had been donated under the Anatomy Act. The experiment was not authorized by the Act, nor was it done with the Coroner’s permission therefore it was unlawful under the Act. It was not unlawful. Clearly Dr Cala thought it was permissible. The conduct should not attract moral criticism. The conduct indicates a deficiency in the legal education of such people.

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