The court ruled that the Coroner's 'Open Verdict' was erroneous and substituted it with a finding of homicide due to inadequate medical treatment leading to the deceased's death.

Abdul Wahab Mohamed J:

Introduction

[1] This is an appeal on the decision of the Coroner made on 16 June 2023 ("appeal"). This criminal appeal was filed on 30 June 2023 by the appellant's counsel, M/s Daim & Gamany ("counsel").

[2] The appellant is the father of one Soosaimanickam a/l Joseph, the deceased who was declared dead on 19 May 2018.

[3] The appellant here appealed against the decision of the Coroner in delivering an "Open Verdict" in the inquest of the deceased.

Background Facts

[4] The deceased was a Trainee Cadet Officer who was undergoing the Royal Malaysian Navy Trainee Cadet Officer Training (hereafter referred to as his "cadet training") at KD Sultan Idris 1 ("KDSI 1") that began on 12 May 2018.

[5] A week after he started his cadet training, on 19 May 2018 was declared dead by the Hospital Angkatan Tentera (hereafter referred to as "HAT") at 1.45 pm.

[6] On 19 May 2018, the deceased took part in a supervised physical training, whereby the deceased informed one of the Navy Officer on duty that he was unable to continue with the training because he feels tired, weak and had difficulty breathing, hence he was pulled aside and instructed to undergo light training by himself.

[7] Afterwards, all the Trainee Cadet Officers were instructed to go back to the hostel where the deceased was found to have spilled while showering, in a weak state. He was loaded into a car and brought to HAT, and was pronounced dead at 1.45 pm.

[8] A post mortem was conducted by Medical Officier Dr Saravanan a/p Suppiayah at the Seri Manjung Hospital at 20 May 2018 where it was concluded that the cause of death was Pulmonary Oedema.

[9] The issues that bring rise to this appeal is with regard to the Coroner's determination regarding the cause of death and the manner by which the deceased passed away, which is directly linked to the conclusion of the criminality involved in the death of the deceased.

[10] The thrust of the appellant's appeal is that cause of death is Pulmonary Oedema caused by Leptospirosis, the Malaysian Royal Navy ("TLDM") officers has denied the deceased to report sick to acquire medical examination and treatment and the act of denying the deceased to report sick barred the deceased from getting treatment which ultimately led to his death.

The Law Governs An Inquest Proceeding

[11] In Malaysia, inquests are referred to as inquiries of death and they are governed by Part VIII, Chapter XXXII of the Criminal Procedure Code and Practice Direction of the Chief Justice No 2 of 2019.

[12] The major task of the Coroner is to investigate a "cause of death". Section 328 of the CPC stated,

"In this Chapter the words "cause of death" include not only the apparent cause of death as ascertainable by inspection or post-mortem examination of the body of the deceased, but also all matters necessary to enable an opinion to be formed as to the manner in which the deceased came by his death and as to whether his death resulted in any way from, or was accelerated by, any unlawful act or omission on the part of any other person."

[13] Due to this effect, s 337 of the Criminal Procedure Code (" CPC ") further stated that:

"A Magistrate holding an inquiry shall inquire when, where, how and after what manner the deceased came by his death and also whether any person is criminally concerned in the cause of the death."

[14] In other words, pursuant to s 337 of the Criminal Procedure Code , the terms of the Inquiry are as follows:

i When the deceased died?

ii. Where the deceased died?

iii. How the deceased died?

iv. On what manner the deceased came by his death?

v. Whether any person is criminally liable in the cause of the death of the deceased?.

[15] Sulong Matjeraie J (as he then was) in In Re Anthony Chang Kim Fook, Deceased ; 2007 MarsdenLR 2799 where he had this to say:

[7] Section 337 of the CPC serves as the terms of reference within which the Coroner conducts the inquest into the death of the deceased. As such the Coroner cannot act outside the per