Forensic aspects of the 2009 Victorian Bushfires Disaster

Abstract

The 2009 Victorian Bushfires Disaster started on a record hot day in February 2009 and resulted in over 300 separate fires with a death toll of 173 and over 400 presentations to hospital emergency departments. This occurred a little over a week after a heat wave in which over 400 people were thought to have died prematurely in southeastern Australia. The Victorian Institute of Forensic Medicine in collaboration with the police force and the State Coroner's Office and over 100 colleagues from all over Australia, Indonesia, New Zealand and Japan implemented a DVI process based on Interpol guidelines to identify the deceased persons. CT scanning was conducted on all remains collected and played a pivotal role in the identification processes in conjunction with experts in pathology, anthropology, forensic odontology and molecular biology. This paper outlines the scale of the disaster and the work, from a forensic medical perspective, to identify the deceased.

Full text

Forensic aspects of the 2009 Victorian Bushfires Disaster
§
Stephen M. Cordner *, Noel Woodford, Richard Bassed
Victorian Institute of Forensic Medicine and Department of Forensic Medicine, Monash University, 57-83 Kavanagh St., Southbank 3006, Australia
1. Introduction
Saturday, February 7, 2009, was the hottest day ever recorded in
the state of Victoria, Australia, the temperatures reaching 46.4 8Cin
Melbourne [1]. In many areas northwest storm force winds
approached and even exceeded 90 kph, whilst over the rest of the
state, winds were from 40 to 60 kph [2]. Fire Danger Indices were
well into the extreme category in nearly all of the State. The
previous hottest day in Victoria was 45.6 8C on January 13, 1939,
the day of the Black Friday bushfires when 71 people died.
The 2009 Victorian Bushfires Disaster, better known as the
Black Saturday bushfires, was a conglomerate of over 300 grass,
scrub or forest fires extending over much of Victoria during early
February (summer in Australia). The final death toll from this
tragedy was 173 deaths, 164 of whom were included in the
resultant DVI operation, the remaining 9 individuals being those
who died fighting the fires or were victims who died in hospital.
The fires started in a variety of ways: a number are thought to be
the result of faulty overhead power lines, others are thought to be
the work of arsonists, the remainder being due to lightning strike.
Many fires were initiated by spotting from existing fires, burning
embers being carried by high winds and creating new fire fronts
kilometers ahead of the original fire. During the afternoon, a dry,
southerly change swept across the State, which simply fanned the
flames in different directions. Whilst the fires were not completely
extinguished for six weeks, virtually all the deaths occurred on
February 7.
This paper outlines the scale of the disaster and the responses to
it from the perspective of the Victorian Institute of Forensic
Medicine, the organization responsible for the scientific aspects of
the Interpol Disaster Victim Identification process.
2. Outline of the heat wave and bushfire disasters
The fires involved 4500 km
2
, destroyed 2000 houses and a
further 3500 structures. 78 towns were directly affected by the
fires and 7500 people were rendered homeless. A total of 173
people died, 24 patients were admitted to burns units, 95 other
patients admitted to hospital and 295 people were treated for
burns in emergency departments and discharged [3].
Table 1 shows the number of deaths from Australia’s nine worst
natural disasters. Five of these nine disasters were bushfires
involving south eastern Australia. In the two weeks before the
Black Saturday bushfires, Victoria (and South Australia) suffered
from an even worse natural disaster as measured by lives lost: a
heat wave.
The current estimate from Victoria’s Chief Health Officer is that
there were 374 excess deaths in Victoria as a result of the heat
wave [4]. This is likely to be an under-estimate because it is based
only on deaths in the period January 26–February 1, the actual days
of the heat wave. These deaths involved the most vulnerable in the
population: the elderly, the isolated and those who were
cognitively impaired, especially where there were other underly-
ing illnesses. These individuals were exposed because of the
Forensic Science International 205 (2011) 2–7
ARTICLE INFO
Article history:
Received 20 May 2010
Received in revised form 6 August 2010
Accepted 10 August 2010
Available online 15 September 2010
Keywords:
Forensic science
Forensic pathology
Victorian bushfires
Disaster victim identification
ABSTRACT
The 2009 Victorian Bushfires Disaster started on a record hot day in February 2009 and resulted in over
300 separate fires with a death toll of 173 and over 400 presentations to hospital emergency
departments. This occurred a little over a week after a heat wave in which over 400 people were thought
to have died prematurely in southeastern Australia. The Victorian Institute of Forensic Medicine in
collaboration with the police force and the State Coroner’s Office and over 100 colleagues from all over
Australia, Indonesia, New Zealand and Japan implemented a DVI process based on Interpol guidelines to
identify the deceased persons. CT scanning was conducted on all remains collected and played a pivotal
role in the identification processes in conjunction with experts in pathology, anthropology, forensic
odontology and molecular biology. This paper outlines the scale of the disaster and the work, from a
forensic medical perspective, to identify the deceased.
Crown Copyright ß2010 Published by Elsevier Ireland Ltd. All rights reserved.
§
This paper is part of the special issue entitled ‘‘Forensic medical response to the
2009 Victorian Bushfires Disaster’’ Guest edited by Olaf H. Drummer and Stephen
M. Cordner.
* Corresponding author. Tel.: +61 3 96844301; fax: +61 3 96827353.
E-mail address: stephen@vifm.org (S.M. Cordner).
Contents lists available at ScienceDirect
Forensic Science International
journal homepage: www.elsevier.com/locate/forsciint
0379-0738/$ – see front matter . Crown Copyright ß2010 Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.forsciint.2010.08.008

relentlessness of the heat wave, as seen in Table 2. The daily mean
temperature provides a better estimate of heat exposure than the
daily highest temperature, leading to increased mortality.
The heat wave was a major disaster in its own right, but one
which has been overtaken in the public consciousness by the
bushfires. It also affected the response by the VIFM to the bushfires.
Table 3 shows the admissions of deceased persons to the mortuary
of the Institute in the fortnight leading up to the bushfires
compared with the same fortnight 12 and three months previously.
The number of admissions from the heat wave exceeded VIFM’s
body storage capacity and autopsy/case management capability.
Early in the week prior to February 7, contingency plans for body
storage were activated so that, for the first time in VIFM’s 21 year
history, numbers of deceased were being housed off-site. 30
deceased from the heat wave were still awaiting examination on
February 7. Thus, when the bushfires struck, the mortuary at the
VIFM was full (with additional bodies stored off-site) and there
was a significant backlog of cases awaiting the initial steps of the
medico-legal death investigation.
No mass disaster is homogeneous in nature and this was
certainly true of the bushfires. This heterogeneity has important
implications for the forensic pathology management of such an
incident. Whilst the primary imperative of a DVI operation is one of
the accurate victim identification, the diverse range of legitimately
interested parties are likely to have other imperatives, e.g. criminal
prosecution of any arsonists; speedy results for families.
Other aspects of the heterogeneity of the bushfire disaster
challenged the forensic investigators: the large number of
geographically dispersed scenes (145), many with difficult fire
affected access; different types of scene (indoors, outdoors, in
motor vehicles); destruction of buildings; co-mingling of remains
(including with animals); variability in the preservation and
integrity of the remains, and the different means by which the fires
where thought to have started. Whilst ‘acts of God’ such as
lightning strike were considered responsible for many of the fires,
police suspected arson in some, and later investigations highlight-
ed possible irregularities in the maintenance of high-voltage
power lines. Additionally, unlike disasters involving closed
populations with finite numbers of victims, the number of
fatalities could only be estimated at the outset, with numbers
ranging from 150 to over 300 deceased persons, the final number
remaining unclear for some weeks.
The legislative responsibility for the overall investigation of
deaths in circumstances such as the bushfires resides with the
Victorian State Coroner. This responsibility co-exists with the
operational responsibility of the State DVI Commander, an
Assistant Commissioner of Victoria Police. The DVI operation
exists to assist the Coroner to make the ultimate judicial finding
about the identity of the deceased. Within this framework sits the
Victorian Institute of Forensic Medicine, an independent statutory
medical and scientific organization with responsibility to provide
forensic pathology and related scientific services for Victoria. This
includes undertaking the medico-legal death investigation for all
deaths reported to the coroner (which may well include autopsy).
This paper does not deal with the State Coroner or Victoria Police’s
direct responsibilities. Suffice to say that these were substantial,
and that a high degree of co-ordination was required by all three
organizations to produce the successful outcome.
3. Human identification processes
Understanding the forensic aspects of the Black Saturday
bushfires requires an understanding of the Interpol DVI process.
(This paper does not include any consideration of aspects related to
arson investigations.)
Human identification is the attribution of the correct name to
human remains. The core of human identification is the compari-
son of ante-mortem data, gathered from friends, family and health
care providers of the missing person, with post-mortem informa-
tion gleaned from a thorough examination of the remains of the
deceased. The usual comparisons involve: visual identification,
fingerprints, dental information and/or DNA testing.
The different areas of comparison relied upon to identify human
remains can be set out diagrammatically as in Fig. 1. Human
Table 1
Number of deaths from Australia’s nine worst natural disasters.
Year Natural disaster/disaster Location Deaths
2009 Heatwave VIC and SA 374 in VIC [4] and 58 in SA [5]
1899 Cyclone Mahina Cape York, Qld >400
2009 Victorian Bushfires VIC 173
1852 Gundagai floods NSW 89
1983 Ash Wednesday bushfires VIC and SA 75
1939 Black Friday bushfires VIC 71
1974 Cyclone Tracy NT 71
1967 Tasmania Bushfires TAS 62
1926 Bushfire VIC 60
Adapted from [3].
VIC, Victoria; TAS, Tasmania; NT, Northern Territory; NSW, New South Wales; Qld, Queensland; SA, South Australia.
Table 2
Temperatures in Melbourne from January 26 to February 1, 2009.
Day Max.
temperature (8C)
Min.
temperature (8C)
Mean
temperature (8C)
MON 26 25.5 14.4 19.9
TUES 27 36.4 16.6 26.5
WED 28 43.4 18.8 31.1
THU 29 44.3 25.7 35.0
FRI 30 45.1
a
25.7 35.4
b
SAT 31 30.5 22.5 26.5
SUN 1 33.8 20.3 27.0
a
At the time, second hottest Victorian day ever.
b
Highest mean ever recorded in Victoria in over 100 years.
Table 3
Admissions to the VIFM in the fortnight to February 8, 2009, compared with two other fortnights.
January 26–February 8, 2009 January 26–February 8, 2008 October 26–November 8, 2008
Total admissions 268 136 129
Average per day 19 10 9
S.M. Cordner et al. / Forensic Science International 205 (2011) 2–7
3

identification involves any combination of one or more of the
above modalities adding up to the identification of the human
remains to the satisfaction of the decision maker. The above
diagram does not give due weight to the significant role of forensic
odontology, which is crucial (see below). Also, it is insufficiently
appreciated that circumstances can quite properly play a role in
identification.
The conduct of this DVI operation was aided by the
implementation of the computer DVI matching program DVI
Sys
1
(Plassdata), which utilizes the Interpol forms in a digital
format. This program serves to act as a repository of all ante-
mortem and post-mortem information, and has the ability to
provide matches between the two data sets based on several
different characteristics, for example, dental restorations.
4. The Victorian framework of the disaster response
In Australia, management of the fatalities in a mass disaster is a
multi-disciplinary undertaking involving police, specialist forensic
personnel and the office of each State Coroner. In the Victorian
coronial system, the Coroner – a non-medical, legally trained
judicial officer – is legislatively required to find the answers to four
questions: who the deceased was, the cause of death, how death
occurred (often construed as the manner of death and necessitat-
ing an examination of the circumstances surrounding a death) and
the particulars necessary for the formal registration of the death.
The Victorian Institute of Forensic Medicine (VIFM) is an
independent statutory authority operating from a purpose built
facility providing medico-legal death investigation services to the
Victorian State Coroner. For this purpose, the Institute is staffed by
forensic pathologists and other specialist forensic personnel
(including odontologists, anthropologists, molecular biologists
and toxicologists) who examine bodies and specimens, prepare
reports and opinions, and provide evidence in subsequent coronial
and other legal proceedings. Under the Coroners Act (Vic) 1985 [6],
the Institute is charged with conducting investigations to provide
advice to the coroner about the four questions set out above.
Under legislation existing at the time [6] coronial authorization
for medico-legal investigation of a death was required before
examination of bodies could proceed. Thus, at the outset, a meeting
was held with the coroner and agreement reached over what the
medical and scientific examination of the remains should entail.
The approach ultimately adopted was predicated upon the
reasonable (but potentially falsifiable) inference that the cause
of death in all cases could be assumed to be, ultimately, the ‘effects
of fire’. This phraseology was specifically chosen to capture deaths
resulting directly from fire (i.e. from smoke inhalation or radiant
heat) as well as indirect effects (possible myocardial infarction
whilst fleeing fire, or death/severe injury caused by building
damage). Thus the decision was taken to treat the medico-legal
death investigation primarily as a process of identification with
additional investigation and dissection as appropriate to confirm
identity, and the mechanism of death. For example, in relatively
intact bodies, examination of the abdomen was conducted to
determine the presence of gall bladder and appendix, the trachea
was opened to look for the presence of soot, and samples were
taken for toxicological analysis. Further dissection was undertaken
in a small number of bodies if pre-autopsy CT scanning revealed
injuries possibly inconsistent with the circumstances. The utiliza-
tion of a restricted or partial autopsy approach was heavily
informed by the availability of CT scan data which enabled,
amongst other things, the ability to identify prostheses, ascertain
the degree of commingling of remains (both human and animal),
identify some items of personal property, and exclude significant
ante-mortem trauma such as head or chest injuries.
Implicit in the approach outlined above was an acknowledge-
ment by all interested parties that some issues might arise at a later
date which could remain unresolved. For example, families seeking
information about the precise cause and mechanism of death,
estimations of survival times, and the contribution of factors such
as natural disease or motor vehicular trauma to the death. These
issues were subordinated to the main aims of pursuing accurate
and timely identification of the remains and reasonable conclu-
sions about the cause and mechanism of death.
[(Fig._1)TD$FIG]
Fig. 1. Diagrammatic representation of the elements relied upon in human identification. Visual recognition does not form part of the formal Interpol DVI process. (Based on a
diagram provided courtesy of Dr M. Tidball-Binz, Forensic Co-ordinator, International Committee of the Red Cross, Geneva, Switzerland.)
S.M. Cordner et al. / Forensic Science International 205 (2011) 2–7
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5. The Interpol DVI process
At what point the Interpol DVI process should be initiated is a
subjective assessment. From experience, it is actually quite easy for
two individuals who have died in one event to be presented from
the scene to the mortuary in such a way that they are confused and
misidentified. This, plus the importance of institutions being well
trained in the DVI response, means that the process should be
initiated often. The Interpol DVI process is a systematic approach to
human identification which formalizes the outline in Section 3
above. It separates the process of human identification into five
phases:
1.
Scene
2.
Mortuary
3.
Ante-mortem information
4.
Reconciliation
5.
Debrief
This process is set out in an internationally accepted way with agreed
reporting formats [7]. This has the distinct advantage of all the
relevant agencies within, and between, jurisdictions working with the
same set of procedures and associated forms. This was of considerable
practical benefit as agencies from other jurisdictions assisted. Table 4
shows the large number of external organizations who became
involved in this operation, highlighting the necessity for standard
operating protocols.
Operationally, in the Black Saturday bushfires, the five phases
were coordinated in the first instance by daily briefings/meetings
involving the three main agencies involved: State Coroners Office,
Victoria Police and the Victorian Institute of Forensic Medicine. By
week two, these meetings were reduced to three times a week with
all Phase Coordinators, and coordinators of the different aspects
within the phases. So that, for example, attending from the VIFM
were the coordinators of: Pathology; Mortuary; Anthropology;
Odontology; Scientific Services; Administration; Building Services;
and the overall VIFM Coordinator.
5.1. Phase 1 (scene)
Scenes were attended by police teams, some of whom were
trained in specific DVI protocols, whose function was to determine if
human remains were present and if so, to collect them in a manner
which preserved continuity of those remains to a precise location
within the scene. This required mapping the scene, recording it,
securing and labeling the remains for the purposes of evidential
continuity so there was no confusion with any other remains. 14
scenes were in the open and human remains were found in 8 motor
vehicles. There were 145 scenes from which 300 DVI cases were
generated. (A DVI case number is allocated to all remains which are
possibly human and from one person, retrieved and secured at the
scene). The public urgency attached to retrieving as many and as
much of the remains as soon as possible was recognized and acted
upon, which meant that many of the scenes were not attended by
VIFM scene specialists. It turned out, as was to be expected, that it
was necessary to revisit some 86 scenes with experts (pathologists,
odontologists,anthropologists and/ormortuary scientists) to ensure
that no human remains were overlooked. Protocolsarising out of the
debrief process conducted following the completion of this DVI
operation concerning recovery of remains are discussed in the paper
by Bassed and Leditchske [9].
At the time of writing, over one year later, no human remains
relating to the bushfires have been found other than through the
formal Phase 1 DVI process. That is, it would appear that obvious
human remains have not been overlooked. Given the necessary
heavy reliance on non-medical and non-scientific police personnel
in Phase 1, this would appear to be a considerable achievement.
5.2. Phase 2 (mortuary)
Although VIFM staff were involved in all DVI phases, Phase 2
was the direct responsibility of the Institute with considerable
assistance of external personnel.
On the night of February 7, notification of a possible 12
deceased persons was made, activating the DVI plan. (In fact, by
this time, most of the 173 deaths had already occurred). This
resulted in a meeting the next morning of the various coordinators
(Mortuary, Scientific Services, Odontology, Administration, Pathol-
ogy and Facilities Management) to begin implementing the
response. All available pathologists and mortuary staff were called
in to clear the backlog of ‘‘routine’’ cases (including those deceased
from the heat wave).
At this stage about 40 deceased had been discovered, however
many more deaths were anticipated. Plans were implemented to
cater for up to 300 deceased persons. Contingencies were activated
to obtain additional mortuary storage space to handle up to this
number. These facilities required water connections, electricity,
and a good quality marquee including a passageway into the
mortuary proper. This was complete by the Monday evening,
February 9. At the same time security fencing was erected, with
related access arrangements managed by police.
Already by this time, massive support was being offered from
all quarters, including numerous colleagues and the Department of
Justice to which the Institute is administratively responsible. From
the outset there was a major extra burden placed on administrative
staff to keep track of staff and volunteer movements, arrange their
travel and accommodation, ensure their adequate induction,
obtain undertakings and other information from contractors and
volunteers, obtain supplies, arrange catering on site for the
duration of the exercise, amongst other things. The importance
of good performance in this domain for the overall success of the
operation is often under-estimated.
IT staff under the control of the Institute were required to
arrange additional cabling, including network hubs, and the
installation of 26 additional computers with access to DVI Sys
1
.
VIFM coordinators began equipping and staffing up for their
specific components of the Phase 2 response. This included
additional pathologists, odontologists, mortuary technicians,
Table 4
Organizations which contributed services and/or personnel during the DVI
operation.
ACT Health ACT Pathology
Alzheimer’s Australian (QLD) Inc. Austin Hospital
Australian Federal Police (AFP) Australian Navy
Australian Society of Forensic
Odontology
Ballarat Health Services
Bendigo Hospital Pathology
Services
Department of Forensic
Medicine (Sydney)
Dental Health Services
Victoria (DHSV)
Forensic Science SA
Griffith University Hunter New England Health
Department of Medicine
Merit Consulting NSW Health
NZ Defence Force Pathwest Laboratory Medicine WA
Peter Mac Callum Cancer Institute Queensland Health
Queensland Health Forensic &
Scientific Services
Royal Melbourne Dental Hospital
St. John of God Pathology Sydney Dental Hospital
University of Melbourne University of Newcastle
University of Otago
(on behalf of NZ Police)
Victoria Police Forensic
Services Department
Westmead Hospital
S.M. Cordner et al. / Forensic Science International 205 (2011) 2–7
5

anthropologists and molecular biologists. In consultation with
Victoria Police, existing arrangements for the necessary other
components of mortuary based teams were activated, such as
photographers, note-takers, exhibits officers and finger print
officers.
Radiology assumed a major role in the triage process whilst
remains were still in body bags, and subsequently in the formal
identificationprocesses used in the mortuary.Post-graduate fellows
from Malaysia and Japan, assisted the Institute radiologist [9].
The role of the CT scanner was pivotal in our response to this
disaster, although the degree to which it could help was very much
dependent on the type and scale of the disaster and the nature of
the remains being examined. The CT scanner was purchased as part
of Victoria’s response to preparing for possible terrorist events
ahead of the 2006 Commonwealth Games in Melbourne. This, in
turn, was a response to the Bali bombings. In the five years of
operation until the bushfire disaster it became a integral part of
everyday casework and had been used in smaller scale disasters,
such as light plane crashes [8]. On a daily basis it contributes to the
quality of our medico-legal death investigations and provides
valuable information on parts of the body which are not routinely
or easily examined in detail during autopsy (e.g. skeleton of the
spine, limbs, scapulae, face). In some cases, it may provide
sufficient information to answer the questions in particular cases
such that the necessity for autopsy from a coronial point of view is
by-passed.
The specific function of the CT scanner in this disaster was to
triage all DVI cases prior to formal physical examination. This
triage enabled VIFM medical and scientific staff to know what was
present in the body bags prior to opening them. In many cases
information such as age (dentition), gender (anthropology),
presence of medical prostheses (pathology), and the presence of
both human and non-human commingling of remains, was able to
be provided as a result of CT scanning. Further details regarding the
contribution of the CT scanner can be seen in O’Donnell et al. [10],
and Bassed and Hill [11] in this journal.
Table 5 sets out the contribution of the CT scanner during the
response to the bushfires.
There were 300 DVI cases submitted from the scenes
representing ultimately 163 individuals, no remains being located
for one individual. The large number of commingled and
fragmented remains created difficulties not only for forensic
medical investigators, but also for the Coroner, in terms of how to
treat these remains. Some of these remains could be re-associated
back to a particular individual, but more often than not, because of
the degree of incineration, they were unable to be assigned. Human
remains which were determined by examination to be anatomi-
cally identifiable as a defined body part underwent extensive
investigation by molecular biologists, anthropologists, and pathol-
ogists in an attempt to assign them to an individual during the
pathology review process. This review process included perusal of
all scene images, all autopsy images, all CT images, and careful
reading of the completed Interpol forms. Those remains which
were unable to be anatomically classified, such as fragments of
long bones, and which could not be linked by location and/or
compelling circumstance to a particular individual, were classified
as unknown human remains.
In the case of commingled remains which were unable to be
separated into discrete individuals, and where circumstances
indicated the individuals involved belonged to the one family, next
of kin were consulted about their wishes in relation to the remains
being released in this commingled fashion. In cases where
unrelated individuals were commingled, body parts which could
be definitely identified were separated out, and the remaining
fragmentary remains were labeled as ‘‘unidentified’’.
5.3. Phase 3 (ante-mortem)
Phase 3 involves the collection of ante-mortem data. This is the
information that ultimately was compared with the data collected
in Phase 2 (and Phase 1) to enable specific identifications to be
recommended to the Coroner. This phase involved the collection of
medical records, dental records, ‘‘Guthrie’’ cards (being the drop of
blood that is taken at birth from almost all those born in Victoria
for the purposes of testing for inborn errors of metabolism, e.g.
phenylketonuria). The card is retained and stored and the DNA
profile of the blood can be directly compared with the DNA profile
of deceased remains for the purposes of identification. Phase 3 also
involved the structured interview of next of kin in order to gather
information about the missing person who is feared to be dead.
This information included matters such as the height, weight, hair
length and color, particular distinguishing marks such as skin
blemishes or tattoos, any jewellery and the clothing being worn
when last seen. These are obviously very difficult interviews for
families; they were conducted by a team of 130 police detectives,
accompanied by grief counselors.
Forensic odontologists were involved in helping to obtain
dental records. In some cases this included obtaining the assistance
Table 5
The contribution of the CT scanner to identification.
With CT scanner Aspect Without CT scanner
Information about contents of DVI case (e.g. commingled remains;
animal remains; adult/child/gender; personal belongings;
prostheses; dental information) available upon scanning
immediately following admission
Early
information
Information about contents of DVI case not available until
body bag opened under controlled circumstances in the
mortuary days or even weeks later
Much identifying information (as above) could be seen,
and pathologist could be directed to items of specific importance.
This provides valuable information in its own right, and
speeds and improves the quality of the post-mortem
examination. Each case examined in the mortuary with
the benefit of a CT scan report available. Pathologists/
anthropologists/dentists started by knowing what they
were looking for and where it was
Early
information
Pathologist proceeds in complete absence of any such
information and must discover and evaluate all the elements
ab initio. This can be difficult, especially in circumstances of
the effects of fire
The CT scan provides a user friendly record of much of the
identifying material, both in terms of subsequent
review or answering later questions and in terms of showing
to lay people including coroners (and even families)
Records Heavy reliance on photography which is a single two dimensional
representation, contains much extraneous material including
conveying the reality of the human remains in a way which is
avoided by radiological imaging (some photography still very
important)
The above elements mean that the mortuary based work
could be prioritised and matched more
effectively to the skills and resources available
Work flow Simply approach the work on a one by one case basis in
a triaging vacuum
S.M. Cordner et al. / Forensic Science International 205 (2011) 2–7
6

of medical insurers to provide names and addresses of dentists
who had provided care so that records could be obtained. Clinical
forensic physicians from the Institute were involved in reading
through the medical records looking for anything that might assist
with identification, such as previous surgery, insertion of
prostheses or illnesses that might be expected to be detected.
All ante-mortem data collected was entered onto DVI Sys
1
by
police, and by members of the odontology and clinical forensic
medical teams.
5.4. Phase 4 (reconciliation)
Reconciliation is the process whereby ante-mortem and post-
mortem data are matched, thus providing a scientifically robust
conclusion concerning the identity of a particular set of human
remains. This process involves input by all forensic disciplines, as
well as circumstantial evidence gathered in Phase 1 and Phase 3. In
order that the inevitable and complex cross-linkage of case
numbers and individuals might more easily be comprehended by
the coroner, a review of all case numbers was performed by the
pathology coordinator along with the mortuary manager, odon-
tologist, anthropologist, police member and molecular biologist.
This review process had the additional advantage of a centralised
case review prior to release of remains so that any possible
discrepancies or inconsistencies might be addressed.
Whilst the medico-legal examination of the remains was
directed primarily to issues of identification, the ultimate legal
confirmation of identity could only be made following formal
judicial, coronial decision. To that end, and at the end of the process
of mortuary and ancillary investigations, a series of identification
boards were held at which medical and scientific evidence was
presented to the Coroner. This process was complicated since there
were more DVI case numbers than presumed deceased individuals
(300 cases representing 164 individuals).
Phase 4 brings together all the information gathered and
synthesizes it to produce the identification brief which is
presented to the Coroner at the Identification Board. The
Identification Board was not a public hearing, but its proceedings
were recorded in the event this was something families wished to
hear, or to have transcribed. At the Board, the Victoria Police Officer
assisting the Coroner presented the reasons why the remains were
thought to be those of a particular named person. The relevant
specialists presented the specific aspects of the dental, molecular
biological (DNA) or anthropological results that formed the basis of
the particular identification. Further details regarding the specifics
of each discipline’s contribution are presented in other papers in
this journal [9–20].
Managing the huge amount of information is a particular
challenge. It is beyond the scope of this paper to critique the value
of DVI Sys
1
in the response to this disaster.
5.5. Phase 5 (debrief)
The Institute conducted its own in-house debriefing exercise
as well as participating in a comprehensive process, with an
external facilitator, involving the State Coroners Office and
Victoria Police. This was completed in time for its outcomes to
be available and implemented as far as possible prior to the
2009/2010 fire season [9].
6. Conclusion
This is an overview of a highly complex organism that came into
existence to respond to the demands of human identification
following a mass disaster. It concentrates on the role of the
Victorian Institute of Forensic Medicine. It does not do justice to
the contribution of well over 100 colleagues from all over Australia,
Indonesia, New Zealand, and Japan who came and gave their time
to help. It does not cover the role and work of the State Coroners
Office and Victoria Police. It does not do justice to the families of
those who died, in whose name all this happens, who have gone
through a time the rest of us cannot really imagine.
The final identifications were formally made by the State
Coroner on May 7, 2009, exactly three months to the day of Black
Saturday.
Acknowledgements
The authors acknowledge the many people and organizations
who assisted in response to the Victorian bushfires disaster. This
paper is based on a presentation by the first author to the
Australian Academy of Forensic Science, Sydney, August 2009, and
also upon a presentation by the third author to the American
Academy of Forensic Science, Seattle, February 2010.
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