By Loretta Lohberger, ABC
John Santi holds a photograph of his brother, Tony. Photo: ABC / Ebony ten Broeke
Pathologists working in Tasmania between 1966 and 1991 may have "actively sourced" body parts from coronial autopsies to give to a museum without the knowledge or consent of families - or of the coroners who were responsible for the bodies when the specimens were taken - a coroner has found.
Coroner Simon Cooper has released his findings from an investigation into 177 specimens held in the collection of the R A Rodda Museum of Pathology at the University of Tasmania in Hobart.
The investigation started in 2016, after the museum contacted the Coroners' Office with concerns about three specimens it had in its collection that appeared to have been retained without the consent of families or the coroner.
"It appears at this stage that now-dead forensic pathologist Dr Royal Cummings was the person who provided the large majority of coronial specimens to the museum," Cooper said.
"However, it also appears that his predecessors and successors also engaged in the practice.
"It also appears that pathologists may have actively sourced specimens from coronial autopsies to give to the museum, as well as providing specimens that had been retained for forensic purposes under the Coroners Act 1957."
Coronial autopsies are autopsies that form part of coronial investigations.
Generally, coroners investigate deaths that are unexpected or unexplained. Their remit also includes deaths in custody.
While a coronial investigation is being done, the coroner has control of the body. It is then formally released to the family for burial or cremation.
Under the laws that applied at the time, and under current laws, body parts sourced or retained as part of investigations into the cause of death "cannot be used for medical research or education, at least not without the knowledge and consent of relevant family members", Cooper said.
"This is the case notwithstanding that the motivation of the pathologist may have been benevolent."
'Feeling of distress will never end'
Coroners also did not have the power to authorise the retention of a body part for any purpose other than for investigating the manner and cause of death.
"I think it is reasonable to state that the expectation of families is (and would have been) that the body of their loved one is complete," he said.
"The retention of human remains without family or coronial approval, or even knowledge, is an historic practice out of keeping with, and offensive to, contemporary standards and values.
"It is inconceivable to my mind that it would ever happen again, although the fact that the practice continued for as long as it did and ended only comparatively recently is also almost equally inconceivable," Cooper said.
John Santi, whose brother Tony died in a motorcycle crash in the 1970s, found out this year that Tony's brain had been kept in the Rodda Museum's collection. It has since been buried with Tony's body.
"The feeling of distress … it will never end, it will never go away, but in saying that, I'm glad the coroner has finished his part of it," Santi said.
"[The coroner's report] is not the end of it because some people have got to be held accountable.
"To me, it's stealing of body parts and justice has to be served."
Alby*, whose two-year-old daughter Amy died in 1984 at the Royal Hobart Hospital, and from whom a specimen was retained without the knowledge of her family, said it took him a couple of days to bring himself to read Cooper's report.
"It's just again all these … reminders of what's gone on, so it's quite disturbing to see the extent of this," he said.
University apologises
The University of Tasmania's deputy vice-chancellor for health, Graeme Zosky, said the university was "deeply sorry for the sadness and hurt felt by family members who learned that parts of their loved ones were collected during coronial autopsies and retained without consent".
"This historic practice no longer occurs and has not for several decades," Professor Zosky said.
He said the university would "carefully consider the coroner's report to determine any further actions".
Concerns raised in early 2000s
The issue of specimens being retained from bodies without consent made headlines around the world in 1998, following an investigation into the deaths of 29 babies who died after having heart surgery at the Bristol Royal Infirmary in the 1980s and 1990s.
It was found that specimens had been kept from the babies without the knowledge or explicit consent of their families.
There were also inquiries in Australia, including the Walker Inquiry in New South Wales in 2001, which raised concerns about the retention of organs at autopsy.
In response to those concerns, a national set of guidelines and a code of practice for autopsy procedures was developed.
"It is apparent that following the Walker Inquiry, the relevant minister and department were made aware of the practice in Tasmania, but no action was taken. I also observe that inaction included not advising the Coronial Division of the practice," Cooper said.
The Rodda Museum contacted the Coroners' Office in 2016, saying there were three bone specimens in the museum's collection, sourced from coronial autopsies in 1982, "that had apparently been retained … without the consent or approval of a coroner or the families involved".
It was later determined that the number of samples retained by the museum after coronial autopsies was 177.
Of those, about 100 were able to be identified and were dealt with in accordance with the families' wishes, "where possible".
Those that were unable to be identified, or for which no family members were found, were "respectfully disposed" according to the relevant laws, Mr Cooper said.
He said the investigation involved complex manual searches and reconciliation of records, "with little additional resources" provided to the Coroners' Office to do the work.
Cooper ordered in 2018 that the 177 specimens be removed from display.
He did not make any recommendations.
*Name has been changed for privacy reasons.
- ABC
