The appropriate standard of proof in a Malaysian death inquiry is the balance of probabilities, not beyond reasonable doubt, particularly in cases involving potential unlawful actions by authorities.

[1] I have had the benefit of reading the separate judgments of my learned brothers, Mah Weng Kwai JCA and Hamid Sultan Abu Backer JCA, with whom I agree that this appeal from the decision of the learned judge in the High Court should be allowed.

[2] This is my separate judgment in which I wish to add to, and qualify, a number of issues addressed by my learned brothers.

A. Procedural Background

[3] This appeal is an appeal against the decision of the learned High Court Judge who heard the matter in His Lordship's revisionary jurisdiction (under s 341A of the Criminal Procedure Code (" CPC ")) over the decision/verdict of the learned Magistrate sitting as a coroner to inquire into the cause of death of one Teoh Beng Hock. The sudden death report was referred to the Magistrate by the Public Prosecutor under s 339 of the . The Magistrate conducted the inquiry/inquest under s 337 of the same.

[4] The learned Magistrate arrived at an open verdict after a very lengthy inquiry.

The CPC Provisions

[5] For reasons that will become apparent later in this judgment, it will be relevant to consider the exact terms of these relevant provisions of the CPC . I reproduce the relevant parts below:

"S 339. Power of Public Prosecutor to require inquiry to be held.

(1) The Public Prosecutor may at any time direct a Magistrate to hold an inquiry under this chapter into the cause of, and the circumstances connected with, any death such as is referred to in ss 329 and 334, and the Magistrate to whom such direction is given shall then proceed to hold an inquiry and shall record his finding as to the cause of death and also as to any of the circumstances connected with it with regard to which the Public Prosecutor may have directed him to make inquiry ...

S 337. Inquiries to be made by Magistrate.

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."

[6] These provisions are broadly formulated, and it would appear, at least from the statutory wording, that the mandate of the Magistrate sitting as a coroner extends beyond finding the immediate cause of death.

[7] For contextual purposes, it will be also appropriate at this juncture to consider as well s 328 which provides the statutory "meaning" of "cause of death", as follows:

"328. Meaning of "cause of death".

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."

[8] I am reproducing these provisions in full to underline the thrust the appeal has taken. Subsequent to the promptings by this panel, counsel for the parties have submitted at length on the underlying principles to give meaning and effect to our own rules of law, as against the available comparative jurisprudence - in our case, the laws in the United Kingdom, the Australian States and India.

The Criminal Revision Proceedings

[9] It has to be noted that this death inquiry under the CPC has attracted much public attention, and has been described generally by the public as "the Teoh Beng Hock's case." The family of the deceased, being dissatisfied with the verdict of the Magistrate sought a review of the verdict before the High Court Judge. The High Court heard the review proceedings/crimina