Findings of the Mock Coronial Enquiry

Coroner finding smallDr Hendtlass’s “findings” were presented at a meeting on 19 April 2012 at the hall of the Royal Society of Victoria. The following summary of her conclusions was published in the April 2012 newsletter of the Royal Society of Victoria. The full text of her findings has been published and is available from the Royal Society of Victoria.

Summary of Conclusions

”I have reached the conclusion that the primary cause of the deaths of Mr Burke, Mr Wills and Mr Gray was nutritional inadequacy including starvation and beriberi associated with thiamine deficiency. This failure to provide enough food for four men for the journey to the Gulf and back to Cooper Creek was totally attributable to Mr Burke’s lack of suitability for the role of leader of the Exploring Expedition. He was authoritarian, unschooled and inexperienced. He made mathematical mistakes in calculating how much and what food he needed to take with him. He refused to consult with the indigenous people who knew how to manage toxicity associated with eating nardoo. He and Mr Wills dismissed Mr Gray’s illness as malingering when it probably reflected nutritional inadequacy. However, Mr Burke and most of the Exploring Expedition were appointed by the Expedition Committee. Further, the Expedition Committee knew or should have known about the risks they were exposing the Expedition to in sending them across Australia in the summer, they knew Mr Burke’s limitations as the leader of Expedition in those circumstances, they maintained a tight rein on Mr Burke until he left Menindie and their instructions required him to comply with their directions until he left Cooper Creek. The Exploring Expedition then gave him full discretion to act as he thought appropriate. General Cosgrove told the mock Inquest : “I don’t think their role can be seen to have been constructive and productive but rather, at best, passive.” And later: “There is no doubt that the Royal Society subcommittee which was monitoring and setting up this Expedition did not display great gumption or leadership when they started to see symptoms of this thing falling apart.” 1 Therefore, although Mr Burke accepted leadership responsibility for the Exploring Expedition, the Exploration Committee must share responsibility for the consequences of his inability to lead the Expedition to success and safety.2 Further, Mr Burke could not have known that the diet he offered his colleagues was deficient in thiamine and that this would compound his natural irascibility and intellectual inadequacy. I am also unable to exclude other contributing factors including other toxic reactions, infections and the effect of dehydration.”

Dr Jane Hendtlass, Coroner

DATED: 19 April 2012

1 Peter Cosgrove, evidence, mock Inquest, 23 July 2011.
2 Peter Cosgrove, evidence, mock Inquest, 23 July 2011.