Introduction
In a significant Supreme Court of Victoria decision on 11 June 2024, Justice Quigley dismissed an appeal brought by Dr. Sean Runacres against the findings of Coroner Simon McGregor. The case centred around the tragic death in custody of Veronica Marie Nelson, a proud woman of Gunditjmara, Dja Dja Wurrung, Wiradjuri, and Yorta Yorta heritage. The ruling affirmed the rigorous scrutiny applied by the Coroners Court to the failed medical practices within the custodial system.
Background
Veronica Nelson died on 2 January 2020, at the Dame Phyllis Frost Centre. Her death was classified as a 'reportable death' under section 4 of the Coroners Act 2008 (Vic). After a coronial inquest, Coroner McGregor published his landmark findings on 30 January 2023, which included several adverse findings against Dr Runacres, who conducted Veronica's initial medical assessment.
Dr Runacres sought to quash specific adverse findings made by the Coroner, arguing that these findings were not supported by the evidence and that the Coroner had misapplied the evidentiary standards. As the appeal was between Dr Runacres and the Coroners Court, Aunty Donna Nelson, Veronica’s mother, and James Leonard (‘Percy’) Lovett, Veronica’s longtime partner, jointly applied to intervene in the appeal. Robinson Gill Lawyers and the Victorian Aboriginal Legal Service were granted permission as ‘intervenors’ by the Supreme Court and written and oral submissions were made on the substance of the appeal.
The Appeal
The three main points of contention by Dr Runacres were as follows:
- Failure to Conduct Physical Examination: The Coroner had found that Dr Runacres did not physically examine Veronica on 31 December 2019.
- Inaccurate Weight Recording: The Coroner had concluded that the weight recorded by Dr Runacres was inaccurate.
- Chain of Inadequate Medical Treatment: The Coroner had stated that Dr Runacres' actions set in motion a series of inadequate medical treatments.
Supreme Court’s Findings
Ground 1: Physical Examination
Justice Quigley upheld the Coroner’s finding that it was not open to conclude that Dr. Runacres conducted a physical examination. The evidence, including CCTV footage, indicated that it was highly unlikely that such an examination was conducted in the brief time frame shown. Dr. Runacres' notes were found to be unreliable as they were not contemporaneous and lacked accuracy.
Grounds 2 and 3: Application of Briginshaw Standard and Weight of Evidence
The Court found that the Coroner correctly applied the Briginshaw standard, which requires a higher level of certainty given the gravity of the findings. Justice Quigley found that the evidence was weighed carefully, and the Coroner’s conclusions were supported by the available evidence. The Court found that it was reasonable for the Coroner to conclude that Dr Runacres did not physically examine Veronica.
Grounds 4 and 5: Recording of Veronica's Weight
The Coroner’s finding that the weight recorded by Dr Runacres was inaccurate was upheld. The discrepancy between Veronica's recorded weight and her weight at the time of the autopsy could not be explained by natural weight loss processes. The evidence from Dr Baber, who performed the autopsy, supported the Coroner’s conclusion.
Ground 6: Chain of Inadequate Medical Treatment
Justice Quigley determined that the statement at [541] of the Coroner’s report was not an appealable statutory finding. Instead, it was part of the continuum of analysis leading to the ultimate finding. Even if it were considered a finding, it was not against the weight of the evidence to the extent that it would be unreasonable.
Conclusion
The Supreme Court's decision to dismiss Dr Runacres' appeal underscores the importance of coronial inquests in scrutinizing medical practices within custodial settings, ensuring accountability and the delivery of justice for individuals like Veronica Nelson. This case reaffirms a poignant reminder of the critical need for diligent medical care and accurate record-keeping within the prison system.
How can I learn more?
Sarah Condon.
Principal Lawyer.
Sarah Condon is a Principal Lawyer in the Crime & Advocacy Department at Robinson Gill.
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