Stanton and in the Matter of the Coroners Act 1957
[1987] TASSC 32
•4 May 1987
TASSC A22/1987
CITATION: Stanton and in the matter of the Coroners Act 1957 [1987] TASSC 32; A22/1987
PARTIES: IN THE MATTER of an Inquest touching the death of
STANTON, Michael Brian and
IN THE MATTER of the Coroners Act 1957, s15(2)
TITLE OF COURT: SUPREME COURT OF TASMANIA
JURISDICTION: ORIGINAL
FILE NO/S: M108/1987
DELIVERED ON: 4 May 1987
DELIVERED AT:
HEARING DATE:
JUDGMENT OF: Wright J
CATCHWORDS:
REPRESENTATION:
Counsel:
Applicant:
Respondent:
Solicitors:
Applicant:
Respondent:
Judgment Number: TASSC A22/1987
Number of paragraphs: 18
Serial No A22/1987
File No M1081987
REASONS FOR JUDGMENT WRIGHT J
4 May 1987
IN THE MATTER of an Inquest touching the death of MICHAEL BRIAN STANTON
and IN THE MATTER of the CORONERS ACT 1957, s15(2)
This is an application by the Director of Public Prosecutions on behalf of the Attorney General for an order quashing the inquisition taken on the inquest of Michael Brian Stanton which was held before Ivan William Wood Esquire, one of Her Majesty's Coroners for the State of Tasmania on the 22 October 1986 and for an order that another inquest be held touching the death of the said Michael Brian Stanton. The application is made under s15(2) of the Coroners Act 1957 which provides as follows:
"Where an inquest has been held by a coroner, the Supreme Court may, on an application made by, or under the authority of, the Attorney General, if it is satisfied that by reason of fraud, rejection of evidence, irregularity of proceedings, insufficiency of inquiry, or for any reason the court deems sufficient, it is necessary or desirable in the interests of justice that another inquest should be held–
(a)quash the inquisition on that inquest, and order a better inquest; and
(b)make such order as to the cost of and incidental to the application as it thinks fit."
The principal functions of a coroner in Tasmania are defined in s7(1) of the Coroners Act 1957 in the following terms:
"(1)Subject to this Act, where a Coroner is informed that a person has died within the State and–
(a) there is reasonable cause to suspect that the person has died –
(i) a violent or unnatural death; or
(ii) a sudden death of which the cause is unknown;
…
the coroner has jurisdiction to inquire into, and shall inquire into, the manner and cause of that person's death."
In Jervis on Coroners, 9th ed at 26 – 27 the following passage appears:
"It might be thought that now so much of the coroner's jurisdiction has been taken away the coroner no longer has any significant role to play in modern society; that his office has become an anachronism which can quietly be suppressed."
Following this the learned authors discuss the shift of emphasis from inquest to post mortem examination and continue as follows:
"Nevertheless, although Inquests have declined numerically, their importance when used is still considerable. They can, and should, afford a quick and cheap method of drawing public attention to circumstances which merit investigation. Suspicious circumstances attaching to a death, even though there is no suggestion of murder or manslaughter, are one example. Thus the relatives of a deceased person may feel that the deceased died owing to the negligence or inefficiency of medical authorities: there have been, for instance, several recent cases connected with the admission of patients to mental or other hospitals. If there has been any dereliction from duty, the facts are brought out into the open for all to judge; equally if the suspicions are unjustified, this also can be exposed and the persons cleared of unjustified suspicion. A properly conducted inquest has advantages in speed and cheapness over alternative judicial proceedings. In the case of deaths from industrial accident or disease the proceedings at an inquest can lead to measures being taken to prevent the recurrence of similar fatalities."
In Bilbao v Farquhar (1974) 1 NSWLR 377 at 386, Bowen JA commented upon the historical development of the office of coroner in the following way:
"The office of coroner in the United Kingdom is, of course, a very ancient one, preceding by some centuries the establishment of any official police force as we know it. A coroner had various functions. The function with which we are concerned is that of inquiring into the manner and cause of death, where there is reason to suspect that a person has died a violent or unnatural death or has died a sudden death the cause of which is unknown. It might have been thought that, upon the establishment of an official police force which had the duty, amongst others, of investigating homicide, the office of coroner might have been found to be no longer necessary, but it did not prove to be so. The coroner's inquest served certain purposes, which were not entirely met by the alternative of police investigation. It was an independent and quasi–judicial inquiry. It was generally conducted by persons having special experience or qualifications for the task. It was public. The publicity of its proceedings operated in two ways. First, it was likely to bring the matter to the attention of persons who might be able to give evidence to assist in determining the manner and cause of death and who might be prepared to come forward. Secondly, the fact that such a public inquest might be held tended to operate as deterrent to potential wrongdoers. Its existence was calculated to meet the demands of, and to give confidence to, relatives of the deceased and the public. Where the death in question occurred while the deceased was in a mental institution or a gaol or was in the custody of the police, the coroner's inquest had a special value, because its existence tended to maintain public confidence in these institutions. The coroner's inquest also served an educational or reforming purpose. Where a particular way of doing things proved to be a lethal trap, the coroner could oftentimes call attention to the danger and sometimes recommend ways of remedying the deficiency. Again, the publicity of its proceedings assisted in this regard. It proceeded untrammelled by the rules of evidence. The coroner in appropriate cases could commit a person for trial."
His Honour also commented upon the New South Wales legislation in relation to recent developments in that State which to some extent, follow the path taken by the Tasmanian Coroners Act 1957. Whilst useful, the discussion of those developments does not appear to me to be particularly relevant to the present case.
It may therefore be said that at the present time a coroner's principal function is to hold an open public enquiry into sudden death for the purposes of either committing any person criminally responsible therefor for trial, or publicly exposing the circumstances in which the death occurred. In the latter event the coroner's inquisition may have significance in terms of statistical and other information of assistance to Government, but in other respects the formal finding has limited effect. It does not have any real bearing upon findings which may be made at a civil trial. It may provoke public debate and lead to political or administrative action, but although such action may be based to some extent upon the coroner's findings, I would expect that more often than not the evidence given at the inquest would be of more significance in this respect than the actual findings themselves. Certainly the consequences of forfeiture of property by a suicide and the right to a die and which sometimes resulted from a coronial inquisition have long since ceased to have any legal effect and have been abolished. As a result, the large majority of inquests tend to have archival, rather than legal, significance in present times.
Omitting the formal parts, the coroner in the present case made the following findings:
"I find that the said Michael Brian STANTON of Stowport in the State of Tasmania, who was born at Adelaide in the State of South Australia on the 16th of March, 1958, died on the 13th of February, 1986, aged 27, on the Old Bass Highway between Forth and Ulverstone in the State of Tasmania of multiple injuries arising from a road accident occurring [sic] on the date of death, that he was not attended by a medical practitioner at the time of his death, and that he was found to be dead when examined by Dr D Hurst at the Mersey General Hospital at Latrobe at 6.58 pm on the 13th day of February, 1986."
Had the coroner's findings terminated at this point there would be little doubt in my opinion that he had complied with the requirements of s12 of the Coroners Act and had fulfilled the proper functions entrusted to him by law. This was not a case in which there was or is, any suggestion that the coroner should have committed any person for trial pursuant to s16 of the Coroners Act.
In addition to the finding reproduced in the passage above (in a form which I might say, has become common throughout this State) the learned coroner went on to include the following material in his inquisition.
The circumstances surrounding his death were as follows:–
"The deceased was riding a motor cycle, proceeding north toward Ulverstone from Forth, and entered a right hand bend, the centre line of which was marked for northbound traffic by a single continuous white line, and for southbound traffic by a single broken white line.
At that time a white Ford Transit van was travelling south around the bend and was being followed by a bronze coloured Gemini sedan driven by Andrew John Page.
At his exit from the bend the deceased was in passing collision with the rear drivers side of the Gemini sedan and was flung off to his left hand verge.
Approaching the bend, the driver of the sedan had started to pull out to pass the Transit van, up till which time the van had blocked visual contact between the sedan and the motor cycle. Upon sighting the approaching motor cycle, the driver of the sedan steered toward his own left hand verge, and damage to the vehicle may be consistent with his still pulling to his left when the collision occurred.
Evidence is inconclusive as to whether any part of the sedan was across the road centre line at the point of impact. The sedan was otherwise being driven correctly and at low speed.
It is noted that the deceased was under the influence of cannabis and some alcohol, but evidence is inconclusive as to whether this was a significant factor in the accident.
Although the motor cycle was travelling at a speed judged greater than that of the sedan, its speed was within legal limits and has not been established as being excessive in the circumstances.
The evidence does not permit me to assign blame for the accident to either driver and I find that death was due to misadventure."
Learned Crown Counsel Mr Cullen, who appeared on the application, deposed in an affidavit sworn on the 5 March 1987, that the application for an order quashing the inquisition was made on the following grounds:
"(a) That the Applicant respectfully seeks from the Honourable Court an order quashing the said Inquisition and for an order that a better Inquest be held touching the death of the said Michael Brian Stanton and that all necessary and consequential directions be given on the following grounds that the enquiry was insufficient.
(i)That the sum total of the blood–alcohol Cannabis analysis by Mr J E Ryall and Dr R S Parsons afforded a combined reading of between .191% and .269% the former being the lesser of the possible levels found in the samples taken from various parts of the deceased's body.
(ii)That the effect of the abovementioned blood levels on the driver of a motor vehicle was a significant factor to be considered and that such expert evidence was available to the Coroner but was not called.
(iii)That the said Coroner fell into error in the said Inquisition by recording a finding of misadventure on the said Michael Brian Stanton, when such finding connotes accident that is something over which there is no human control. That such finding also suggests that the motor cycle was being properly ridden at the time it collided with the motor car being driven by Andrew John Page and that misfortune intervened.
(iv)That a proper consideration of all of the evidence available may well lead to a more specific finding as to the circumstances of the deceased's death."
On the hearing of the application submissions were confined to two propositions. Firstly, that the coroner had failed to address his mind or inform himself sufficiently upon the significance of the blood–alcohol and blood–cannabis levels in the deceased man's body according to the analytical procedures carried out by Mr J E Ryall and Dr R S Parsons. Secondly, that the coroner fell into error in finding and recording that death was due to misadventure.
I will deal with these two propositions together because they appear to me to be interwoven to some extent. Certainly if the only finding had been that death was due to "misadventure" and the more specific observations about the evidence preceding that finding had not been incorporated in the coroner's report, it may be said that such a compendious description suggested an accidental death by a means over which there had been no human control. Nonetheless, the remarks of the coroner as a whole make it perfectly clear, in my opinion, that he was not finding that the deceased's death was due to a pure accident at all. In my opinion, he made a careful analysis of the effect of the evidence and recorded his inability to reach a positive conclusion as to the point on the roadway at which the fatal collision actually took place. This in my opinion, is crucial to an understanding of the other findings that he made. It also is of crucial significance in respect of the first submission made by Crown Counsel, because far from ignoring or misconceiving the effect of cannabis and alcohol the coroner has specifically found "that the deceased was under the influence of cannabis and some alcohol". As I pointed out to Mr Cullen during the course of argument, this in itself does not mean that the deceased should also be found to have been responsible for the accident which caused his death. It may provide a sound basis for drawing an inference that there was some negligence on the part of the deceased, (see for example Rainbird v Ward 90/1969), but it is not obligatory that such an inference should be drawn. If for example, the Gemini sedan driven by Mr Page had suddenly and unexpectedly swerved into the path of the deceased's motor cycle when the vehicles were so close that a collision was inevitable, the intoxicated condition of the motor cycle rider would appear to me to have little if any relevance to the issue of causation of the collision.
I think that what the coroner has done in this case is to analyse the evidence according to the best of his ability and, having done so, he has reached a position in which he has been unable to make any conclusive findings one way or the other on the relative position of the two vehicles at the moment of collision and thus he has been unable to determine whether the deceased's intoxication was causative or not. No doubt he would have been entitled to make positive findings if his assessment of the evidence had permitted him to do so. However, I do not think it appropriate to be critical of his failure to do so. In any event, findings upon such issues as civil negligence are, in my opinion, more appropriately made by civil courts in the event of civil proceedings being instituted between the drivers of the motor vehicles involved or their personal representatives. I think the coroner's findings in the present case exceeded those which are required by law, of a coroner conducting an inquest into death in this State.
This however is not a basis for criticism, nor is it a basis in my view for concluding that there has been an insufficiency of enquiry in the present case. In any event, I am quite unable to conclude that it is desirable in the interests of justice that another inquest should be held on discretionary grounds.
That this court has a broad direction to either grant or refuse such an application as this appears quite clear (Lang v Registrar General of the State of Victoria [1950] VLR 307). In my view no good reason has been shown for re–opening this matter and the application should be refused.
Because of the course that I am adopting it is unnecessary for me to consider whether or not the application to quash the inquisition should have been served upon the coroner and other persons with an interest in the outcome. This certainly seems to have been the practice in other jurisdictions upon similar applications being made in the past. The Tasmanian legislation appears to be silent upon this point but as a matter of general procedure I incline to the view that service upon interested parties should be required notwithstanding the non existence of Rules of Court as provided for in s15(8). This may well be an issue to be considered in detail upon a future application.
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