Inquest into the death of Ronald Reeves

CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Ronald John REEVES Hearing dates: 7 March 2022 Date of findings: 7 March 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: 2019/159733 Representation: Mr. T. O’Donnell, Solicitor and Coronial Advocate Assisting the Coroner Ms C. Moore , Solicitor, for Corrective Services New South Wales Ms. N. Szulgit, Solicitor, for Justice Health Findings: Identity Ronald John Reeves Date of death 17 May 2019 Place of death Canberra Hospital, Canberra, Australian Capital Territory Cause of death The combined effects of the complications of ventilation associated pneumonia, acute respiratory distress syndrome and hypoxic ischaemic encephalopathy following a medical event of unknown aetiology Manner of death Natural Causes Recommendations Nil Non-publication orders: See Annexure A

1. Introduction 1.1. At the time of his death, Ronald Reeves was 70 years old and in lawful custody at the Goulburn Correction Centre (‘GCC’), Goulburn, New South Wales, on remand.

1.2. On 9 July 2018 Mr. Reeves was charged with murder, driving recklessly, furiously or at speed or manner dangerous, and common assault. Mr Reeves was refused bail and thereafter held on remand.

1.3. On the morning of 22 April 2019 Mr. Reeves was found unconscious in his bed by his cell mate. Emergency services attended and Mr. Reeves was taken by Ambulance to Goulburn Base Hospital and later flown to Canberra Hospital, where he remained until he died on 17 May 2019.

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. Secs. 23 and 27 of the Act make 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. Reeves did not identify any evidence to suggest that he was not appropriately cared for and treated while in custody.

3. Mr. Reeves’s life and background 3.1. Mr. Reeves was born on 8 December 1948 and was aged 70 at the time of death. The brief otherwise contains very little information about his life. Mr Reeves lived in the Newcastle / Raymond Terrace area for most of his life and was employed on farms. There is no information in the brief about his marriages, and he had two adult children from whom he was apparently long estranged. In 2012 Mr. Reeves was separated from his wife and he formed a de facto relationship with Janice Garrett who he had apparently known for many years. The relationship ended in mid-2018 and its end was the catalyst for the events that gave rise to the charges against him.

4. Mr. Reeves’s custodial history 4.1. After Mr. Reeves was charged he was refused bail and thereafter held on remand, initially at the Shortland Correctional Centre at Cessnock. On 13 September 2018 Mr. Reeves was moved to the Metropolitan Reception and Remand Centre at Silverwater and then transferred to GCC on 29 October 2018.

4.2. At the date of his death Mr. Reeves had been in custody on remand for 10 months and 8 days.

5. Mr. Reeves’s medical history 5.1. Mr. Reeves had a known history of chronic ischaemic heart disease, including previous myocardial infarctions and multiple stent insertions, haemochromatosis, hypertension, depression and the sequelae of a motor vehicle accident on the day of the events that gave rise to the charges.

5.2. Mr. Reeves underwent a Reception Screening Assessment when he first entered custody, which included a mental health assessment, and Mr. Reeves denied suicidal ideation or

thoughts of self-harm. After initial assessment the evidence shows that Mr. Reeves had further contacts with Justice Health in relation to his mental health, although on each occasion he denied any thought of self-harm or suicidal ideation. Mr. Reeves was provided with counselling and advice however, while in GCC, he declined further assistance.

5.3. Mr. Reeves’ final contact with Justice Health was on 22 April 2019 in the circumstances described below.

6. 22 April 2019 6.1. On the evening of 21 April 2019 Mr Reeves and his cell mate were locked in the cell at 18.51.

6.2. On the morning of 22 April 2019 the cell doors were opened at 08.47 and Mr. Reeves’ cell mate approached a Corrective Services New South Wales (‘CSNSW’) Officer and informed him that he was unable to wake Mr. Reeves. The Officer enters the cell and unsuccessfully tries to wake Mr. Reeves. Justice Health nurses arrive and enter the cell at

08.51. An Ambulance is called and arrives at 09.12. Treatment was continued until 09.53 when Mr. Reeves was taken from GCC by Ambulance Officers for transport to Goulburn Hospital

6.3. On admission to Goulburn Hospital Mr. Reeves was intubated before later transfer by helicopter to Canberra Hospital.

7. Canberra Hospital 7.1. On arrival at Canberra Hospital Mr. Reeves underwent a CT scan of the head with an aorto-cerebral arteriogram, with no significant findings. A urine drug screen detected benzodiazepines, tricyclic antidepressants, propofol, paracetamol, lignocaine and quetiapine metabolites. Subsequent investigations showed no significant findings other than an ECG on 24 April 2019 which was suggestive of metabolic encephalopathy.

7.2. On 7 May Mr. Reeves had a further CT scan of the brain, chest, abdomen and pelvis, again with no significant findings. On 14 May an MRI scan of the brain showed indications that were favoured to represent hypoxic ischaemic encephalopathy.

7.3. Mr. Reeves failed to make any meaningful recovery and on 17 May 2019, after consultation with his family, support was withdrawn and he died later that day.

8. The cause Mr. Reeves’s death 8.1. Mr. Reeves was taken to the Department of Forensic Medicine in Sydney where a postmortem examination was performed by Dr. Jennifer Pokorny, forensic pathologist, on 17 May 2019.

8.2. In the autopsy report dated 2 June 2020 Dr. Pokorny opined that terminal events leading to Mr. Reeves’ death were the combined effects of the complications of ventilation associated pneumonia, acute respiratory distress syndrome and hypoxic ischaemic encephalopathy although the underlying cause of his initial presentation was unascertained, and according the cause of death was unascertained. The report discusses a number of possible causes of the underlying event including Mr. Reeves extensive ischaemic heart disease, which could have triggered an arrhythmia and the initial collapse, an infection not detected at autopsy after the prolonged treatment with antibiotics while hospitalised and the various drugs identified on the urine screen on 22 April.

8.3. In relation to the possible contribution of the drugs, a further report was obtained from Professor Alison Jones, Specialist Physician and Clinical Toxicologist. Prof. Jones analysis excludes as a possible cause all of the drugs found on the urine screen with the exception of the Quetiapine and opioids and ultimately concludes that the most likely sequence of events is that Mr. Reeves ingested an excess amount of Quetiapine which caused respiratory depression and he then developed a hypoxic brain injury which caused his death. Prof. Jones’ analysis cannot, and does not, exclude the possibility of an arrhythmia triggered by Mr Reeves’ ischaemic heart disease as postulated by Dr Pokorny.

9. Conclusions 9.1. The evidence establishes on the balance of probabilities that the cause of Mr. Reeves’ death was the combined effects of the complications of ventilation associated pneumonia, acute respiratory distress syndrome and hypoxic ischaemic encephalopathy following an underlying medical event. There are a number of possible causes of that event and, on the evidence, no rational basis to choose between them. For that reason the proper conclusion is that the underlying event is of unknown aetiology.

9.2. 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.

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

10. Findings 10.1. The findings I make under sec. 81(1) of the Act are: Identity Ronald John Reeves Date of death 17 May 2019 Place of death Canberra Hospital, Canberra, Australian Capital Territory Cause of death The combined effects of the complications of ventilation associated pneumonia, acute respiratory distress syndrome and hypoxic ischaemic encephalopathy, following a medical event of unknown aetiology Manner of death Natural Causes

11. Closing 11.1. I acknowledge and express my gratitude to Mr. T O’Donnell, Solicitor and Coronial Advocate, for his assistance both before and during the inquest. I also thank Detective Senior Constable Stuart Harris for conducting the Police investigations and for compiling the initial brief of evidence.

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

Reeves’s family.

11.3. I close this inquest.

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