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Summary of judgment in the matter of Runacres v The Coroners Court of Victoria [2024] VSC 304 delivered on 11 June 2024.

Summary of judgment

Runacres v The Coroners Court of Victoria

11 June 2024

Today, the Trial Division of the Supreme Court (Quigley J) dismissed an appeal by Dr Sean Runacres against certain findings made by Coroner McGregor (the ‘Coroner’) of the Coroners Court of Victoria (‘CCV’) in the inquest into the passing of Veronica Nelson delivered on 30 January 2023 (‘Report’).

Veronica1, a proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman, passed away whilst in the State’s custody on 2 January 2020 at the Dame Phyllis Frost Centre (‘DPFC’). The appellant was the registered medical doctor who conducted the ‘reception medical assessment’ (‘RMA’) of Veronica upon her arrival at the DPFC on 31 December 2019.

Veronica’s death constituted a ‘reportable death’ pursuant to s 4 of the Coroners Act 2008 (Vic) (‘Coroners Act’). In accordance with s 67 of the Coroners Act, the Coroner made a large number of statutory findings across a range of matters connected with Veronica’s death, including specific adverse findings against the appellant.

The appellant brought his appeal under s 83(2) of the Coroners Act and sought to quash three findings made by the Coroner at paragraphs 528, 520 and 541 of the Coroner’s Report. These findings were that a physical examination of Veronica was not conducted on 31 December 2019, the weight of Veronica recorded by Dr Runacres was inaccurate, and that Dr Runacres set in motion a chain of events in which Veronica’s medical treatment and care was inadequate in an ongoing way.

The appeal is limited to a coroner’s statutory finding (as opposed to a comment or recommendation). The appeal is limited to a question of law. In order to succeed in the appeal, the appellant was required to identify an error of law in the Coroner’s findings. In this appeal, the Court is not empowered to substitute the Coroner’s findings with its own view of the evidence.

The appellant argued the Coroner erred in finding that certain findings of fact were ‘not open’ to him, that the Coroner failed to weigh the evidence in accordance with the applicable evidentiary standard, and/or that the findings were against the evidence and the weight of the evidence to such an extent that no reasonable coroner could have made the findings.

The Court found that the Coroner correctly understood the evidentiary standard applicable to him and he properly weighed the evidence in accordance with it. The Court found that the findings at paragraphs 528 and 520 were open to the Coroner on the evidence before him, and were not against the evidence and the weight of the evidence to such an extent that no reasonable coroner could have made them.

The Court found that the statement at paragraph 541 is not an appealable statutory finding for the purposes of the Coroners Act. Instead, it was found to be a preliminary conclusion forming part of the continuum of analysis which underpinned a separate statutory finding at paragraph 542.

At trial, the Court granted leave to intervene in the proceeding to Aunty Donna Nelson, Veronica’s mother, and James Leonard (‘Percy’) Lovett, Veronica’s longtime partner. Written and oral submissions were made by the intervenors on the substance of the appeal.


NOTE: This summary is necessarily incomplete. It is not intended as a substitute for the Court’s reasons or to be used in any later consideration of the Court’s reasons. The only authoritative pronouncement of the Court’s reasons and conclusions is that contained in the published reasons for judgment.

[1]Veronica’s family requested that the deceased be referred to by her first name and this was adopted throughout the trial of this proceeding by all parties.

Supreme Court of Victoria
Supreme Court of Victoria
Date of publication