Inquest into the death of Ricardo Damien Arquero

CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Ricardo Damien ARQUERO Hearing dates: 18 February 2022 Date of findings: 18 February 2022 Place of findings: Coroner’s Court of New South Wales Findings of: Magistrate Brett Shields, Deputy State Coroner Catchwords: CORONIAL LAW – death in custody, cause and manner of death File number: 2019/258876 Representation: Ms. K. Mackay, Coronial Advocate Assisting the Coroner Ms C Moore, Solicitor for Corrective Services New South Wales Mr H Norris, Solicitor for Justice Health and Forensic Mental Health Network Findings: Identity Ricardo Damien Arquero Date of death 19 August 2019 Place of death Glen Innes Correction Centre, Glen Innes, New South Wales Cause of death Bronchial Asthma Manner of death Natural Causes Recommendations Nil Non-publication orders: See Annexure A

1. Introduction 1.1. At the time of his death, Ricardo Arquero was 40 years old and in lawful custody at the Glen Innes Correctional Centre (‘GICC’), Glen Innes, New South Wales, serving a term of imprisonment.

1.2. On 19 August 2019 Mr. Arquero was found in his cell in a distressed state and having difficulty breathing. Emergency services attended however Mr. Arquero could not be revived and he was pronounced deceased at the scene.

2. Reason for the inquest 2.1. The Coroners Act 2009 (‘the Act’) requires a Coroner to investigate a ‘reportable death’, as that term is defined in the Act, to enable a Coroner to the make the findings required by sec. 81 of the Act. The findings concern the identity of the person who died, when and where they died, and the cause and the manner of their death. In this context the manner means the circumstances in which they died.

2.2. A person charged with a criminal offence, or who is sentenced to a term of imprisonment upon conviction, can be detained in lawful custody and, in so doing, the State assumes responsibility for the care of that person. Sec. 23 of the Act makes an inquest mandatory in cases where a person dies while in the custody of the State. The open administration of justice requires, and the community appropriately expects, that the death of a person in the custody of the State will be properly and independently investigated to ensure that the State met its responsibility for the care of that person.

2.3. The coronial investigation into the death of Mr. Arquero did not identify any evidence to suggest that he was not appropriately cared for and treated while in custody.

3. Mr. Arquero’s life and background 3.1. Mr. Arquero was born in Canberra on 28 January 1979 and was aged 40 at the time of his death. Mr. Arquero had 2 siblings and he grew up with his family in Canberra, before the family moved to Melbourne, returned to Canberra and then moved to the Gold Coast, primarily because of Mr. Arquero’s asthma.

3.2. Mr. Arquero was not married and with his partner had one child born in 2019. Prior to his incarceration Mr. Arquero was living in Queenbeyan, New South Wales and without employment.

4. Mr. Arquero’s custodial history 4.1. In February 2018 Mr. Arquero was the subject of a police operation concerning the supply of prohibited drugs and related matters. He entered Corrective Services New South Wales (‘CSNSW’) custody on 18 November 2018 and was thereafter held on remand until he was sentenced.

4.2. Mr. Arquero appeared before the District Court on 22 May 2019 when he was sentenced to an aggregate term of imprisonment of 2 years and 3 months with a non-parole period of 12 months commencing on 10 November 2018. Mr. Arquero’s earliest possible date for release was on 9 November 2019. At the date of his death Mr. Arquero had served the majority of the non-parole period of his sentence and he would have been eligible for release in a little over 2 months.

4.3. After sentence Mr. Arquero was classified as ‘C2 Minimum Security’ inmate and he was held in a number of CSNSW correctional centres until he was transferred to GICC on 13 June 2019. During his time in custody Mr. Arquero had no recorded breaches of discipline and he received many visits from family.

5. Mr. Arquero’s medical history 5.1. Mr. Arquero was diagnosed with asthma when aged 9 or 10 years of age, and his condition was a factor in the family eventually moving to Queensland. His siblings recall Mr. Arquero using a Ventolin inhaler as a child.

5.2. Mr. Arquero underwent a Reception Screening Assessment when he first entered custody in November 2018 which identified his asthma. Mr. Arquero also completed a New Inmate Lodgement and Special Instruction Sheet on which he ticked the box for asthma. Mr.

Arquero was provided with a Ventolin inhaler and Seretide Asthma preventative.

5.3. On 18 December 2018 Mr. Arquero saw a Justice Health officer and he again disclosed his asthma, as well as hearing impairment, and an allergy to Penicillin. He reported no other medical conditions.

5.4. After initial assessment the evidence shows that Mr. Arquero had the following further contacts with Justice Health:

5.4.1. On 16 November 2019 after he threatened self-harm. Mr. Arquero was placed in a safe cell and kept under constant observations;

5.4.2. On 15 May 2019 after he reported difficulty breathing. Mr. Arquero was taken to the clinic and kept under observation until the arrival of an Ambulance. Mr. Arquero was treated by paramedics and remained under observation until the following day when he returned to his cell;

5.4.3. On 1 June 2019 Mr. Arquero was assessed for suitability to transfer to an isolated correctional centre, which included assessment for any exclusionary diagnosis;

5.4.4. On 13 June 2019 on arrival at GICC Mr. Arquero completed a Reception and Accommodation Checklist, and he did not identify any immediate medical requirement;

5.4.5. On 15 August 2019 after Mr. Arquero injured the fingers on his right hand while on work assignment. Mr. Arquero was seen by a general medical practitioner, underwent an x-ray and was assessed as unfit for work for one week; and

5.4.6. On 19 August 2019 in the circumstances described below.

6. 18 & 19 August 2019 6.1. At approximately, 23.35 the ‘Knock Up’ activated and CSNSW officers responded and located Mr Arquero on the common toilet and having difficulty breathing. Mr. Arquero was conscious and another inmate retrieved a Ventolin inhaler and gave it to Mr. Arquero who used it. Mr. Arquero then lost consciousness and he was moved to the bathroom floor, placed in the recovery position and CPR was commenced. A ‘000’ call was made and the Ambulance arrived at 00.20 on 19 August 2019. Mr. Arquero was moved into the common area and CPR was continued by the Ambulance officers however Mr. Arquero could not be revived and he was pronounced deceased at 00.47.

7. The cause Mr. Arquero’s death 7.1. Mr. Arquero was taken to the Department of Forensic Medicine in Newcastle where a postmortem examination was performed by Dr. A. Ward, forensic pathologist, on 22 August 2019.

7.2. In the autopsy report dated 28 February 2020 Dr. Ward opined that the direct cause of death is bronchial asthma.

8. Conclusions 8.1. The evidence establishes on the balance of probabilities that the cause of Mr. Arquero’s death was bronchial asthma.

8.2. There is no evidence to suggest that any action could have been taken by CSNSW or Justice Health to alter the outcome or that any aspect of the medical care provided to Mr.

Arquero while in custody contributed in any way to his death.

9. Findings 9.1. The findings I make under sec. 81(1) of the Act are: Identity Ricardo Damien Arquero

Date of death 19 August 2019 Place of death Glenn Innes Correctional Centre, Glenn Innes, New South Wales Cause of death Bronchial Asthma Manner of death Natural Causes

10. Closing 10.1. I acknowledge and express my gratitude to Ms. K. Mackay, Coronial Advocate, for her assistance both before and during the inquest. I also thank Detective Senior Constable Dale Keegan for conducting the Police investigations and for compiling the initial brief of evidence.

10.2. On behalf of the Coroners Court of New South Wales, I offer condolences to Mr.

Arquero’s family.

10.3. I close this inquest.

Magistrate Brett Shields Deputy State Coroner Coroners Court of New South Wales