State Coroner's Office

The Hon. F. PANGALLO (15:54): What I am about to reveal will shock South Australians and it must lead to an urgent investigation into the egregious conduct inside the office of the South Australian Coroner. It starts with the tragedy and travesty of South Australia's forgotten man. You would never have heard of Steven John Maple, who also went by the alias of Steven Burns. He was a son, a brother, a lost, tortured and troubled soul for most of his adult life, leaving him estranged from his family who had done all they could to help him. There is a sister, Michelle Gibson, living in Perth and an elderly father, Rodney, in the Riverland.

Steven lived a meagre existence in the government-run Barwell apartment housing complex. He was well known to police through his challenges with mental health and alcohol and substance abuse, a loner who was often seen wandering the streets and was under a significant NDIS care package of more than $300,000. Despite his circumstances, he did have family who still cared for him. After all, Steven was a human being, one who lost his way in life through no fault of his own.

It is shameful and a disgrace that South Australia Police, the Coroner's office, the Public Trustee, the NDIS and his providers did not care about Steven when he died. He was found heavily intoxicated by his carer, collapsed on a Norwood street, on 15 November 2023, clutching a bottle of iced coffee and a bottle of vodka, with some possessions. His carer took him back to his Glenside unit. He was found dead in his bed the following day. An ambulance that was called never came.

What followed next is a scandalous case study in incompetence, carelessness and system failure by all those agencies. It highlights the very serious problems with the Coroner's office and the way it is handling cases of deceased persons. Just how many other Steven Maple cases are there?

In Steven's case, it took more than nine months for his next of kin, his father, to be notified of his passing, even though the authorities knew who he was. The Coroner's office lied to the family about that and other information they had collected. Steven's father was initially told by police that his remains had been buried. Then he was told the remains were still in a forensic science unit morgue. He wanted to view his son's body. They told him and his sister, Michelle, they could not because decomposition was so bad that the remains were mouldy and unidentifiable. It distressingly compounded their grief. They asked to see photographs of Steven taken at the external examination when he died, but they were told there were not any. Michelle says the red flags went up. How could they be sure the remains were even Steven's given the conflicting information they had received?

There were unexplained anomalies with Steven's toxicology report and whether a full autopsy was carried out. Michelle turned detective to uncover the truth about what really had happened. She requested further DNA testing to prove to the funeral director that the remains to be collected were his. Again, bureaucratic obstacles were placed in her way, raising suspicion even further of a cover-up and bungling.

An independent laboratory Michelle wanted to use needed more samples—a piece of femur, a tooth and hair and nail clippings. The deputy manager of the Coroner's Court told her that no Forensic Science SA staff were trained or qualified to remove teeth or acquire DNA samples from teeth—incredulous.

The family refuses to collect him until they are convinced they belong to their loved one. Meanwhile, the Coroner's office is bullying the family to remove them or they will hand them to the Public Trustee. This threat has caused the family such great distress that this week they backed down and she was told they would facilitate further DNA testing with an independent laboratory.

They want answers, the truth, from all the agencies, including the NDIS, which needs to explain how they cared for Steven and how his considerable amount of money was spent. In desperation, Michelle wrote a lengthy letter to me seeking my assistance. I seek leave to table that letter and supporting documents.

Leave granted.

The Hon. F. PANGALLO: She closes with this plea:

We simply want the truth and we want to lay Steven to rest…now. He has been treated in death as he was in life. This is so very disrespectful.