Lachie Jones inquest: Pathologist admits his autopsy ‘fell short’

Monday, 13 May 2024

The pathologist who carried out the autopsy on toddler Lachie Jones has admitted that based on his report, it was not safe to conclude drowning was the cause of death.

He also admitted that while he saw no evidence of it, it was not possible to exclude the involvement of an adult in Lachie’s death; and that the autopsy he conducted fell short of a Code of Practice for deaths relating to immersion.

The pathologist, who has interim name suppression, has given evidence in week three of an inquest into the death of Lachie Jones.

Lachie was found dead late on the evening of January 29, 2019, face up in a council oxidation pond near his home.

In response to questioning from Simon Mount KC, for the coroner, the pathologist said he did not usually perform autopsies on children. But he wanted to carry it out in Southland as a favour to the mother and the family, because they did not want to wait for his body to be returned from elsewhere.

He said he was not aware that Lachie’s father Paul had raised concerns about how his son died when he carried out the autopsy, but was aware that there had been an objection to a forensic post mortem.

The autopsy report was reviewed by Dr Alexander Kolar, an expert forensic pathologist in the United Kingdom, and Dr Martin Sage, a forensic pathologist.

Both were critical of the pathologist’s decision not to internally examine the head and brain, which could have indicated a different cause of death, including that Lachie died of natural causes, or of applied neck pressure.

The pathologist said he had checked the eyes for signs of smothering but had not found any.

Mount said Dr Kolar had said in his report that he ''did not consider it safe to conclude drowning was the cause of death''.

When asked if he agreed, the pathologist said, 'on [the] basis of my report, it's probably not safe to say that, no.''

The pathologist also said he called a coroner to consult about the decision not to examine the head, but there was no record of that call.

Legally the pathologist should have also consulted with police about that decision but he said he was not aware of that.

His records of the autopsy, including photographs that were taken, had been stored in a computer system that was no longer in use, he told the court.

He said examining the head and brain was a ‘’controversial subject because Māori don’t like it and islanders don’t like it’’.

When Mount asked if he had any evidence of whether Lachie was a Maori or Pacific Islander, he replied, ‘’Can you tell by looking at somebody?’’

The pathologist admitted he had not done all of the examinations that were expected to be carried out in an autopsy for a body that had been immersed.

“It’s an unnatural death but I didn’t think the circumstances were that unusual — it’s a routine drowning,’’ he said.

The report he received from police said there were no suspicious circumstances.

His finding of drowning was one of “exclusion” because it was the most logical cause of death, and he had excluded other causes, he said.

Qualified mortuary technician gives evidence

On Monday afternoon, qualified mortuary technician Bill Little, who assisted the pathologist, gave evidence, where he said it was his understanding there were no suspicious circumstances regarding the death and there was nothing noted about it being suspicious in a report from the police.

'There was nothing at all to relay that there was an unexplained cause of death.''

In response to questioning from Mount, Little said here was no evidence to suggest Lachie’s body had been in a freezer, and he had the appearance of a well nourished young child.

Little had taken vitreous fluid from the eye and it had been clear, so the body was not frozen, he said.

Lawyer Max Simpkins later questioned him about some purple marks on Lachie’s back, the position of one hand and a bend in one leg.

Little said the position of the hand was likely to exposure to water, and the discolouration and leg position were likely to be due to rigor mortis setting and it starting to make muscles contract.

He said the decision not to examine the head and brain was “made out of compassion”, and it was important to preserve the dignity of the body.