Dianne Brimble's awful death did more than ruin the image of the once-staid cruise industry. It exposed fault lines in a legal system that felt another aftershock this week as the former senior deputy state coroner Jacqueline Milledge handed down her findings.
As the inquest expanded over 17 months, the public and Brimble's family were spared few details of her humiliating death and the despicable behaviour of the eight men with her in her final hours on the Pacific Sky.
Milledge released appalling photographs and showed others of the dying Brisbane mother to media on advice from counsel assisting her. But the tell-all nature of the proceedings fed a tabloid furore and put the woman in charge offside with some in the legal firmament. Milledge has since returned to the local court bench, amid suggestions she missed out on the top coronial job as a result.
She had closed the inquest when she recommended charges against three of the men. Two received good behaviour bonds after not telling police that their friend Mark Wilhelm supplied Brimble with the drug GHB.
In April, after a hung jury and a retrial that went awry, Justice Rod Howie recorded a drug supply conviction but no other penalty against Wilhelm, inspiring headlines such as ''No one will pay!''
In the aftermath, the Director of Public Prosecutions, Nicholas Cowdery, blamed tabloid hysteria and Milledge's inquest for creating ''two myths: first, that a coronial inquest might be some kind of trial rather than an inquiry; and secondly, that the eight people of interest named in that inquiry were almost irrefutably guilty of manslaughter. After the frenzied reporting of the matter at that stage it seemed unlikely that anything short of eight life sentences would appease an outraged public.''
Milledge demanded an apology in a letter to the Attorney-General and suggested Cowdery could be in contempt of court for making ''intimidating'' remarks while the inquest was continuing.
The dispute represents a clash of two cultures in the justice system.
As coroner Milledge was required to search for the truth; as prosecutor Cowdery had to ask the more legalistic question of who might realistically be convicted for it.
Cowdery has also repeatedly called for the abolition of police prosecutors, of whom Milledge was one.
And Milledge has her own history of iconoclasm.
Last year she gave her former police colleagues a serve, saying they had behaved ''like paratroopers'' and describing their version of events as ''nonsense'' when they kicked in a Regent Park grandmother's door, assaulting her and her teenage disabled son.
She did the same this week when she found, contrary to the courts, that Brimble had been ''unknowingly drugged'' for the sexual gratification of others.
Milledge was widely popular with victims and their representatives in her coronial days, and Brendan Nelson once backed her for Australian of the Year.
Yesterday she delivered her recommendations to avoid a repeat of the Brimble case, which are all too often ignored in coronial proceedings. But Milledge made sure they were at least heard loud and clear.Life and times
Born: Sydney, December 15, 1951, only child of Mary, secretary, and Jack, piano tuner and composer.
Educated: J.J. Cahill Memorial High School, Mascot.
Applied to join police three times and finally accepted in 1972 as one of four women. In 1974 transferred to the prosecuting branch, and in 1990 became one of the first two female police prosecutors.
Appointed magistrate in 1996 and senior deputy state coroner in 2000.
Died twice on an operating table in 2006 but revived.
