Roe v Coroner Urquhart - [2021] WASC 397

JURISDICTION : SUPREME COURT OF WESTERN AUSTRALIA
IN CHAMBERS

CITATION:   ROE -v- CORONER URQUHART [2021] WASC 397
CORAM:   SMITH J
HEARD:   8 NOVEMBER 2021
DELIVERED          :   8 NOVEMBER 2021
PUBLISHED           :   11 NOVEMBER 2021
FILE NO/S:   CIV 2153 of 2021
BETWEEN:   ROSEMARY ROE
First Plaintiff
ALICIA ROE
Second Plaintiff
AND
CORONER URQUHART
Defendant

Catchwords:

Coroners Act 1996 (WA) - Application made by senior next of kin for an order that no post mortem examination be performed - Whether it is desirable in all the circumstances to make an order directing the Coroner not perform post mortem examination - Relevance of spiritual and cultural beliefs - Public interest considered - Turns on own facts

Legislation:

Coroners Act 1996 (WA), s 25, s 35

Result:

Application granted
Order made - no further post mortem be performed on the body of the deceased

Category: B

Representation:

Counsel:

First Plaintiff	:	In Person
Second Plaintiff	:	In Person
Defendant	:	BD Nelson

Solicitors:

First Plaintiff	:	In Person
Second Plaintiff	:	In Person
Defendant	:	State Solicitor's Office

Cases referred to in decision:

Evans v Coroner [2011] NTSC 100; (2011) 214 A Crim R 444
Paterson v Coroner King [2019] WASC 25
Re Death of Simon Unchango (Jnr); Ex parte Simon Unchango (Snr) (1997) 95 A Crim R 65

SMITH J:

(These reasons were delivered extemporaneously at the conclusion of the hearing. They have been edited from the transcript to correct matters of grammar, and to include complete references in the form of footnotes.)

Introduction

By a notice of originating motion filed on 1 November 2021, the plaintiffs made an application, pursuant to s 37(3) of the Coroners Act1996 (WA), for an order that no post mortem be performed of the body deceased, Mr Aubrey Ronald Roe.
Mr Roe died on 13 October 2021. He was 56 years old.
The plaintiffs are the daughter of Mr Roe, Ms Alicia Rondell Roe who is his senior next of kin,[1] and his sister, Ms Rosemary Carmel Roe.
[1] As defined in the order of priority in s 37(5) of the Coroners Act 1996 (WA).

The evidence

In support of their application, the plaintiffs each swore an affidavit on 5 November 2021 in which they set out their relationship to Mr Roe and the reasons why they oppose a full post mortem examination of his body. The plaintiffs also filed an affidavit sworn by Mr Roe's oldest child, his son Richard James Roe on 7 November 2021.
The defendant, Coroner Urquhart, opposes the order sought by the plaintiffs. The Coroner filed two affidavits in support of his case. The first is an affidavit by the Principal Registrar of the Coroner's Court, Ms Kelly Marie Niclair affirmed on 4 November 2021, and an affidavit of Dr Joe Wen Ong, affirmed on 4 November 2021.

The circumstances of the death of the deceased

At about 00.31am on 13 October 2021, Mr Roe was seen alive at the Victoria Park transfer station in Burswood. CCTV from the transfer station showed him fall face down onto the floor. Approximately 22 minutes elapsed before a member of the public noticed him lying on the floor, and commenced cardiopulmonary resuscitation. An ambulance was called, and Mr Roe was transported to Royal Perth Hospital where he received medical treatment and was later certified life extinct by a doctor at 1.58am.
The police conducted an investigation into the death of Mr Roe and found no evidence of criminality, third-party involvement or suspicious circumstances surrounding his death.

The death of Mr Roe subject to a Coroner's investigation

On 14 October 2021, Registrar R Whalen issued a notice of written approval to the State Mortuary Manager to carry out a post-mortem examination on or after 7.00am on 15 October 2021 of Mr Roe's body, which notice advised that the death of Mr Roe was subject to a coroner's investigation and that approval to conduct a post mortem was subject to any objections that may be received by the Coroner's Court subsequent to the approval, and prior to the commencement of the post mortem.[2]
[2] Affidavit of Kelly Marie Niclair, page 13, Attachment KMN03.
On 20 October 2021, the Coroner's Court received an email from Ms Rosemary Roe, advising that the family of Mr Roe opposed a post mortem examination of his body, stating that they did not wish for an autopsy.[3] The family referred to their wishes and cultural protocols.[4]
[3] Affidavit of Kelly Marie Niclair par 15 and page 14 Attachment KMN04.
[4] Affidavit of Kelly Marie Niclair Attachment KMN04, page 14.
On the same day, Ms Alicia Roe lodged an objection with the Coroner's Court, citing cultural reasons.[5]
[5] Affidavit of Kelly Marie Niclair par 16 and Attachment KMN05, page 15.
On the same day, Registrar R Whalen issued an authority stating that prior approval for a post mortem examination had been withdrawn (citing the email from the family of the deceased objecting to the post mortem), and granting authority for:
EXTERNAL examination, x-rays, microbiology, toxicology as well as blood sample for DNA comparison and biochemistry testing in association with review of medical notes/information.[6]
[6] Affidavit of Kelly Marie Niclair par 18 and Attachment KMN06, page 16.
Following the receipt of this authority, an external examination of Mr Roe's body, and other tests, and a review of relevant medical notes was undertaken by forensic pathologist Dr Ong on 21 October 2021.
By email dated 28 October 2021, Ms Rosemary Roe reiterated the objection to a full post mortem examination on behalf of the family of Mr Roe, and sought for the body of Mr Roe to be released as soon as possible 'to be able to return to country for burial'.[7]
[7] Affidavit of Kelly Marie Niclair par 21 and Attachment KMN08, page 19.

The Coroner's decision that a full post mortem examination was necessary

On 28 October 2021, the Coroner after considering the objection made by the members of Mr Roe's family decided,[8] pursuant to s 37(1) of the Coroners Act 1996 (WA) that a full post mortem examination was necessary. [9]
[8] Affidavit of Kelly Marie Niclair par 28.
[9] Affidavit of Kelly Marie Niclair Attachment KMN12, page 27 and Attachment KMN13, page 28.
As required by s 37(1) of the Coroners Act, the Coroner provided immediate notice by a letter detailing his reasons for overruling the objection.[10]
[10] Affidavit of Kelly Marie Niclair par 29.
In his written reasons, the Coroner referred to the requirements of s 25 of the Coroners Act, which requires a coroner to find, if possible, how Mr Roe's death occurred and the cause of his death, and stated that without a full post-mortem, a coroner could not find either how Mr Roe's death occurred or the cause of his death. The Coroner referred to the fact that a forensic pathologist:
(a)had conducted an external examination of Mr Roe, including a computerised tomography scan (CT scan) and a toxicological analysis, but was not able to identify a possible explanation for his death; and
(b)had noted that Mr Roe had superficial abrasions present to the front of his face and evidence of previous heart surgery, and indicated that he would not be able to provide an opinion of the cause of death without an internal post mortem examination.
The Coroner also stated in his written reasons that another reason why it was important to find the cause of Mr Roe's death is that he was only 56 years old, and if he died from a sudden medical event, it is possible that the event was caused by a genetic predisposition. For this reason, the Coroner found that a full post mortem examination may identify the predisposition so that Mr Roe's family could take steps to reduce the risk of a similar event happening to them.
In an 'Objection Checklist' completed by the Coroner on 28 October 2021, the Coroner made a hand written record of the reason why he had overruled the objection to a full post-mortem as follows:[11]
Given the age of the deceased (56 yrs & the circumstances of the death (sudden collapse) and noting the lack of specificity of the reasons why the family objects to a PME, I am not prepared to accept the objection.:
[11] Affidavit of Kelly Marie Niclair Attachment KMN 12, page 27.

The forensic pathologist's evidence

Dr Ong, a consultant forensic pathologist based at PathWest, performed an external examination of the body of Mr Roe on 21 October 2021, by conducting an external inspection of the body, taking photographs of the body and obtaining samples for the purposes of toxicology review. A CT scan of the body was also undertaken. [12]
[12] Affidavit of Joe Wen Ong affirmed 4 November 2021 par 6.
Dr Ong identified that the deceased had received his first dose of the Pfizer COVID-19 vaccination on 8 October 2021.[13] Dr Ong was advised by Prof Paul Effler of the Communicable Disease Directorate of the Department of Health of Western Australia that there is an emerging association of mRNA vaccines (which includes the Pfizer COVID-19 vaccine) with inflammation of the heart, also known as myocarditis.
[13] Affidavit of Joe Wen Ong affirmed 4 November 2021 paras 15 - 16.
Dr Ong noted in his report that he would be unable to determine whether that recent vaccination had contributed to the deceased's death from an external examination only, and that, to do so, microscopic examination of the heart tissues would need to be performed to confirm or exclude myocarditis as a potential contributing factor to the death of Mr Roe.[14]
[14] Affidavit of Joe Wen Ong affirmed 4 November 2021 pars 14 and 17.
Subsequent to the preparation of his report, Dr Ong was provided with an interim toxicology report from Ms Sarah McCabe of the Forensic Science Laboratory at the ChemCentre. This report showed the presence of several prescription type medications, along with the presence of methylamphetamine and tetrahydrocannabinol, but indicates that confirmation and quantification of the methylamphetamine and tetrahydrocannabinol remains pending. Dr Ong is of the opinion irrespective of whether any internal post mortem examination is undertaken those results may assist in determining if those drugs have contributed to the death of Mr Roe but will not be able to exclude other potential contributing factors, for example the recent vaccination with the Pfizer COVID-19 vaccine, or any resulting myocarditis.
Dr Ong had regard to a recent outpatient note made on 20 August 2021 when Mr Roe was reviewed at the Cardiology Outpatient Clinic by a Cardiology Registrar, Dr Stephen Arena who recorded in the note that Mr Roe had an aortic valve replacement in 1999 for rheumatic heart disease complicated by Staph aureus endocarditis. Dr Arena described Mr Roe as a pleasant gentleman and noted that the last echocardiogram they had on file was from 2018 at Royal Perth and this showed no complications around the valve. Dr Arena stated in his report that (when reviewed on 20 August 2021) Mr Roe reported doing well, with no symptoms of shortness of breath, no chest pain, was able to work and carry out his daily activities without issues, and walked multiple kilometres a day due to a recent car breakdown. Dr Arena examined Mr Roe and found that he had a clear chest with an audible metallic click but with no murmurs and no dyspnoea. Dr Arena also stated in his report that he organised for Mr Roe to undergo an outpatient echocardiogram and a chart out clinic review.[15] Dr Arena also indicated in his report that it was likely that they would organise yearly echocardiograms.
[15] However, there is no indication from the report that Mr Roe had undertaken an outpatient echocardiogram after the date of his review by Dr Arena.
Dr Ong formed the opinion, as a result of his examination and enquiries and review of Mr Roe's recent cardiology outpatient records from Fiona Stanley Hospital, that the cause of the Mr Roe's death could not be determined.
Dr Ong's opinion is that if a full internal post mortem examination is carried out, he would be able to exclude certain possibilities as to the cause of death of Mr Roe that he could not exclude without a full examination, which include a contribution to death from the recent Pfizer COVID-19 vaccination, or from a natural disease such as heart disease.
Dr Ong is of the opinion that if he was able to conduct a full internal post mortem examination this would allow him to take samples of tissues for histopathology (or microscopic examination) of tissues which may be required to confirm or exclude pathology that may not be easily seen on macroscopic examination (by the naked eye). An example of such pathology would be inflammation of the heart (myocarditis). Further full internal post-mortem examination may also include the taking of samples for microbiology if there is a suspicion of infective changes of the organs of the body seen macroscopically, in order to possibly identify the mechanism that may have caused infection. Such an examination would also permit a referral for neuropathology, if required, for example possible inflammation of the membrane surrounding the brain (meningitis). However, Dr Ong noted, no history of headaches or symptoms of meningitis had been revealed in the information that was available to him.

The plaintiffs' evidence and submissions

The plaintiffs make an application to the court for an order that an autopsy not be performed on the body of Mr Roe, because to do so would result in the plaintiffs and the other members of the Roe family not being able to follow their cultural protocols which would cause them significant distress, compound their grief, loss and add to their intergenerational trauma.
They also submit that to make the order they seek would result in their customary lore being be respected and such an order would be consistent with Closing the Gap targets through supporting their social and emotional well-being.
Ms Alicia Roe in her affidavit states that her father did not want an autopsy and always said he wanted (his body) to return home to Carnarvon. She also states that the process of objecting to an autopsy is preventing her family from organising the funeral in accordance with the customs of their family.[16]
[16] Affidavit of Alicia Rondell Roe sworn 5 November 2021.
Ms Rosemary Roe in her affidavit states that the family of Mr Roe oppose the carrying out of an autopsy of Mr Roe's body for the following reasons:[17]
(1)Mr Roe is a descendant of the oldest continuous living culture in the world. This culture has been taught and handed down orally (and not in writing) through generations, despite colonisation.
(2)Although he did not leave a will, Mr Roe passed down orally to his family that he did not want an autopsy for cultural reasons.
(3)It is her belief and the belief of her family that First Nations peoples are created from their ancestors' spirits, and that the body needs to be whole and intact to proceed on their Journey (to the afterlife).
(4)A surviving aunt and elder of their family, Mrs Valerie Corbett-Roe has passed down her (knowledge of cultural) objections to autopsies and (their belief) that deceased family members should return to Country in Carnarvon for burial.
(5)It is the protocol of the Roe family that deceased members are to be buried no more than two weeks after the date of death with a smoking ceremony and celebration through customary food with extended family and friends consistent with practices of Sorry Business.
(f)The Roe family are of the opinion that the less invasive procedures of blood and urine tests and a CT scan and if necessary, a MRI body scan could be done, but an invasive full post mortem autopsy would cause further distress to the Roe family, in particular, Mr Roe's daughters, grandchildren and great-grandchildren.
(g)The Roe family has had to endure ongoing discrimination, grief, loss and inter-generational trauma, and it is well-recognised that a breach of cultural protocols causes significant distress for Aboriginal peoples.
[17] Affidavit of Rosemary Carmel Roe sworn 5 November 2021.
In his affidavit, Richard Roe states that his father was a smart, spiritual, dignified man who respected every nationality of the world and who had many friends of all different races. He also states that his father had told him during his lifetime on many occasions of his objections 'to any type of thing done to him' and that he would want his wishes respected. From these conversations Richard Roe formed the opinion that his father would object to an autopsy of his body.
The Closing the Gap Targets for Aboriginal peoples referred to by Ms Rosemary Roe were recently reformulated. In March 2019, a new formal Partnership Agreement on Closing the Gap was established between the Commonwealth Government, State and Territory governments, the Coalition of Aboriginal and Torres Strait Islander Peak Organisations and the Australian Local Government Association.[18]
[18] closingthegap.gov.au/partnership.
The 2 July 2020 National Agreement on Closing the Gap has 17 targets.[19] Target 15 is the recognition of the principle that Aboriginal peoples maintain a distinctive cultural, spiritual, physical and economic relationship with their land and waters and Target 16 is the principle that cultures and languages (of Aboriginal peoples) are strong, supported and flourishing. The purpose of these targets is that the knowledge and cultural beliefs and practices of Aboriginal peoples should be valued because such knowledge, cultural beliefs and practices are important for promoting positive cultural identity, and social and emotional wellbeing for Aboriginal peoples.

Legal principles - The discretion conferred on the Supreme Court pursuant to s 37(3) of the Coroners Act

Duties of a coroner

[19] closingthegap.gov.au/national-agreement/targets.

A coroner has jurisdiction to investigate a death if it appears to the coroner that the death is or may be a reportable death.[20] A reportable death is defined in s 3 of the Coroners Act to include a death that occurred in Western Australia which appears to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from injury.
[20] Coroners Act 1996 (WA), s19(1).
The functions of the Coroner include ensuring that all reportable deaths reported to a coroner are investigated.[21]
[21] Coroners Act 1996 (WA), s 8(c).
A coroner investigating a death must find if possible:
(a)the identity of the deceased;
(b)how death occurred;
(c)the cause of death; and
(d)the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1998 (WA).[22]
[22] Coroners Act 1996 (WA), s 25(1).
A coroner is not under a duty to make a finding as to how death occurred, even if it is possible to do so, if there is no duty to hold an inquest into the death under the Coroners Act and the coroner determines that there is no public interest to be served in making such a finding.[23]
[23] Coroners Act 1996 (WA), s 25(1A).
A coroner may comment on any matter connected with the death including public health or safety or the administration of justice.[24]

Principles to be applied by the court in considering whether a post mortem is desirable

[24] Coroners Act 1996 (WA), s 25(2).

As the written submissions filed on behalf of the Coroner point out, in determining an application under s 37(3) of the Coroners Act, the court is not constrained by the coroner's original decision not to order a post mortem examination.
Nor is the court limited to considering whether there has been an error, but is to exercise the jurisdiction afresh and to consider what is desirable in all the circumstances.[25] Consequently, the task of the court is to exercise the jurisdiction afresh, to balance compelling and competing views, and look into what is desirable in all of the circumstances.[26]
[25] Re Death of Simon Unchango (Jnr); Ex parte Simon Unchango (Snr) (1997) 95 A Crim R 65, 70 (Walsh J) and Paterson v Coroner King [2019] WASC 25 [34] ‑ [39] (Strk AJ).
[26] Paterson v Coroner King [2019] WASC 25 [38] (Strk AJ).

Each case must be determined in light of its own facts and circumstances, after a careful and sensitive consideration of all of the relevant circumstances and balancing the identified competing interests.
The factors to be considered include, where relevant, the spiritual and cultural beliefs of the deceased person's family, the public interest, and the statutory obligation cast upon a coroner to find, if possible, the cause of death and how the death occurred.[27]
[27] Coroners Act 1996 (WA) s 25(1).
It may in a particular case be relevant to consider the purpose of an autopsy. The author D Ranson pointed out the purpose of an autopsy is not solely to determine the cause of death but has several aims which may include: confirmation or determination of identity; identification of injuries and natural disease; determination of effects of medical treatment; evaluation of mode of death; provision of an educational resource for the medical profession; provision of tissues for use in medical research and therapeutic procedures; and reconstruction of the circumstances surrounding death.[28]
[28] D Ranson Objections to Medico - Legal Autopsy - Recent Developments in Case Law (2007) 14 JLM 463, 463.
In a matter where without an autopsy the cause of death of an infant could not be ascertained Riley CJ in Evans v Coroner (NT) summarised from the authorities factors that may be relevant to the exercise by the court of the discretion to order that no post-mortem be performed as follows:[29]
[29] Evans v Coroner [2011] NTSC 100; (2011) 214 A Crim R 444 [18] - [19] (footnotes omitted).
By reference to the legislative regime and authorities from various jurisdictions, the following observations may be relevant to the exercise by the Court of the discretion:
(a)the exercise of the discretion to make an order that no autopsy be performed is one that is unfettered;
(b)each case should be decided individually on its own facts and circumstances;
(c)the exercise is one of balancing competing interests;
(d)it is appropriate to take into account the likelihood of, and the extent of, useful information being obtained from the autopsy for the purposes of the Coroner's investigation;
(e)it is appropriate to take into account the genuinely held religious and cultural beliefs of the family of the deceased although those beliefs are not determinative;
(f)in addition, in my opinion, the obligations imposed upon the Coroner under the relevant legislation and the capacity of the Coroner to fulfil those obligations in the absence of an autopsy are to be taken into account although those matters are not determinative.
A range of matters have been identified in various cases as favouring, but not requiring, that an autopsy be held. Those matters include:
(a)where there is evidence pointing to foul play, or suspicious circumstances surrounding the death, which would need to be investigated in order to ensure execution of the due process of the law;
(b)circumstances where there may be a possibility of an outbreak of a serious infection which would need to be investigated in order to cater for public health interests;
(c)cases where it may be in the interests of the immediate family of the deceased to determine whether there is some genetic predisposition to serious disease, that might possibly be treated or detected in its early stages if the possibility of its onset is known;
(d)cases where there is a real issue as to an entitlement to benefits of infant beneficiaries unable to assent to the bringing of an application and it is necessary to resolve the issue for an autopsy to be performed; and
(e)cases where a congenital problem may be disclosed which may be of benefit in preventing other deaths.
The Chief Justice in Evans v Coroner (NT) also relevantly observed:[30]
In matters such as the present case it is incumbent upon the Court to resolve a conflict between the decision of the Coroner that an autopsy is necessary and the competing wishes of family, relatives or friends of the deceased person generally based upon cultural or religious beliefs that are genuinely and strongly held. In some cases it has been held that ascertaining the precise cause of death is less important than the spiritual and cultural beliefs of the family in the particular circumstances. In Wuridjal v Coroner (NT) I adopted the observations of Beach J in Green v Johnstone where his Honour made observations that have been repeated with approval in a number of cases. His Honour said:
In a multicultural society such as we have in this country, it is my opinion that great weight should be given to the cultural and spiritual laws and practices of the various cultural groups forming our society, and that great care should be taken to ensure that their laws and practices, assuming they are otherwise lawful, are not disregarded or abused.
If there were any suspicious circumstances surrounding the death of Leslie Green, I may well have taken the view that the interests of society that the cause of her death be ascertained outweigh the interests of her parents in preserving her body unmutilated by any autopsy. But that is not the situation. All available evidence is to the effect that the infant died from natural causes, probably from the syndrome described as Sudden Infant Death Syndrome. In such a situation it is my opinion that the rights of the parents to be spared further grief as a consequence of their daughter's death outweigh the interests of the community that the actual cause of death be ascertained.
[30] Evans v Coroner [2011] NTSC 100; (2011) 214 A Crim R 444 [21] (footnotes omitted).
On the plaintiffs' affidavit evidence before me, I accept that the family of Mr Roe would experience pain and suffering if his body was subject to an autopsy (a full post mortem) because of their belief that his body needs to be whole and intact to proceed on his journey to the afterlife. I also accept that this belief is shared by his family, and it is a genuinely and strongly held belief which is found generally in Aboriginal culture.
Whilst in other matters it has been found that an applicant's cultural and spiritual beliefs must be balanced against the public interest in the performance of a post mortem,[31] it is my view that the recognition and maintenance of the cultural and spiritual laws and practices of our First Nations peoples, that are otherwise lawful, is also a matter of public interest. This approach was adopted by Riley CJ in Evans v Coroner (NT). His Honour weighed the public interest in knowing the cause of death against the public interest in giving deeply held spiritual and cultural beliefs proper recognition and respect.[32]
[31] See for example the observations of Strk AJ in Paterson v Coroner King [2019] WASC 25 [45].
[32] Evans v Coroner [2011] NTSC 100; (2011) 214 A Crim R 444 [21] (footnotes omitted).
I do not accept the defendant's submission that one of the factors that favours the carrying out of an autopsy of Mr Roe's body is that it is in the public interest that the possibility of one of the causes of death of Mr Roe could have been a genetic predisposition which may affect members of his family. Whilst this was a view taken by the Coroner, there is no medical evidence before the court that a possible cause of death of Mr Roe could be related to genetic causes.
Dr Ong identified that the possible contributory factors to Mr Roe's death were myocarditis as a potential effect of the Pfizer vaccine, or from a natural disease such as heart disease.
It has not been suggested in these proceedings that if it were found following an autopsy that the death of Mr Roe was caused by myocarditis induced by the Pfizer vaccine that such information would add to, or benefit, the body of knowledge about the effectiveness of COVID-19 vaccines and the prevention of death from such vaccines. Further, there is nothing before the court which would suggest that if the cause of the death of Mr Roe was definitively known it would contribute in some meaningful way to the efforts being made to improve health outcomes for other Aboriginal peoples.
Importantly, in this particular matter, the facts of how Mr Roe died and the circumstances surrounding his immediate death are known. The last moments of his life were recorded on CCTV footage at a train station. There is no suggestion that he suffered an injury which caused him to fall or that there were any suspicious circumstances or any suggestion of foul play that surrounded his death. Consequently, the only information that would be obtained from an autopsy would be the medical cause of his death. In this case it has not been suggested that there are or may be any issues relating to public health or safety or the administration of justice on which the Coroner may wish to comment which would be materially assisted by the performance of an autopsy on the body of Mr Roe.
In other matters the medical cause of a person's death would be of significant interest to members of their family. In this matter, the immediate members of the family of Mr Roe are not of the opinion that the exact medical cause of his death should be known.
Consequently, what must be weighed in this case is the public interest of the public generally knowing the exact cause of every sudden unexplained death where there are no suspicious circumstances and the public interest in the recognition and respect of the cultural beliefs of Mr Roe's immediate family.
In all the circumstances, I am of the opinion that, in this case, the interests of the family outweigh the interest in determining the precise cause of Mr Roe's death. For these reasons, an order should be made that no autopsy (full post mortem) of Mr Roe's body be performed.

I certify that the preceding paragraph(s) comprise the reasons for decision of the Supreme Court of Western Australia.
XH
Associate to the Honourable Justice Smith
11 NOVEMBER 2021