Richards, Karen Louise

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Karen Louise Richards TITLE OF COURT: Coroners Court JURISDICTION: Brisbane

FILE NO: 2014/161 DELIVERED ON: 26 July 2017 DELIVERED AT: Brisbane HEARING DATES: 29 September 2016, 28 – 29 November 2016, and 21 February 2017 FINDINGS OF: John Hutton, Coroner CATCHWORDS: Coroners: inquest; mixed drug toxicity; heroin overdose; doctor shopping; excessive delay in rendering first aid; excessive delay in phoning emergency services.

REPRESENTATION: Counsel Assisting: Mr Peter De Waard (Coroners Court of Queensland) Counsel representing Angelo D’Amario: Ms Naadira Omarjee (Bosscher Lawyers)

Contents

Introduction

1. Ms Karen Richards died on 11 January 2014 at 41 years of age due to mixed drug and alcohol toxicity. The police and the deceased’s father raised concerns with me in relation to the potential involvement of a man that was with her at the time of her death, Mr Angelo D’Amario.

2. Mr D’Amario declined to participate in a police record of interview or to provide a written statement to the police. In order to ascertain the circumstances of Ms Richards’ death, I decided to hold an inquest in the public interest.

3. Leading up to the inquest, I conducted an extensive coronial investigation, including: a. Obtaining Ms Richards’ medical records from a range of medical practices, as well as her Medicare and Pharmaceutical Benefits Scheme records; b. Locating and transcribing police audio recordings and 000 audio recordings; c. Directing the police to locate and take statements from several witnesses; and d. A detailed analysis of Ms Richards’ phone records.

4. An inquest was held from 28 – 29 September 2016 and 21 February 2017.

A comprehensive brief of evidence was compiled. I heard oral evidence from the following witnesses: a. Mr Paul Ash (Ms Richards’ former spouse); b. Ms Reve Scott (Ms Richards’ best friend); c. Mr Patrick Mullice (Ms Richards’ neighbour); d. Mr Brian Alderwick (Ms Richards’ friend); e. Ms Janie Sue Palmer (one of Ms Richards’ drug suppliers); and f. Mr Angelo D’Amario (Ms Richards’ spouse at the time of her death and drug supplier).

5. These submissions address the following issues, which were identified at a Pre-Inquest Conference on 29 September 2016: a. The findings required by section 45 (2) of the Coroners Act 2003; namely the identity of the deceased person, how, when and where she died, and what caused her death; and Findings of the inquest into the death of Karen Richards 1

b. Whether any recommendations can be made to reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice.

Findings required by s. 45

6. Pursuant to s. 45(2) of the Coroners Act 2003 (Qld), I find: a. Identity of the deceased – The deceased person is Karen Louise Richards.

b. How she died – As per the circumstances outlined below.

c. Place of death – Ms Richards died at 6 Jeays St, Sandgate, in the state of Queensland.

d. Date of death – Ms Richards died on 11 January 2014.

e. Cause of death – The medical cause of Ms Richards’ death was mixed drug and alcohol toxicity.

Recommendation

7. Section 46 of the Coroners Act 2003 (Qld) provides that a Coroner may comment on anything connected with a death that relates to public health or safety, the administration of justice, or ways to prevent deaths from happening in similar circumstances in the future.

8. I recommend that the Queensland government: Introduce a similar provision to s. 155 of Criminal Code Act (NT) within the Criminal Code Act 1899 (Qld), namely: Provision of rescue, medical treatment and other aid Failure to rescue, provide help, etc.

Any person who, being able to provide rescue, resuscitation, medical treatment, first aid or succour of any kind to a person urgently in need of it and whose life may be endangered if it is not provided, callously fails to do so is guilty of an offence and is liable to imprisonment for 7 years.

9. My reasoning for this recommendation is outlined at paragraphs 134 to 137 of this document.

Findings of the inquest into the death of Karen Richards 2

Evidence, discussion and general circumstances of death Autopsy results

10. A forensic pathologist, Dr Nadine Forde, conducted an external and internal autopsy on 15 January 2014. Toxicology testing was conducted on a sample of femoral blood and a specimen of vitreous humour. The toxicology certificate was issued on 7 March 2014. The autopsy report was issued on 8 April 2014.

11. The external post-mortem examination revealed recent needle puncture marks, as well as crusted lesions over numerous veins, consistent with past intravenous access.

12. The toxicology analysis of Ms Richards’ femoral blood detected: a. Morphine (0.06mg/kg and total morphine (including glucoronides) of 0.36mg/kg). This level is considered potentially lethal; b. Venlafaxine (an antidepressant) 3.0mg/kg. Documented toxic levels are between 1.8mg/L and 15mg/L; c. Diazepam and its metabolite, temazepam, aminonitrazepam (all benzodiazepines); codeine, pericyazine (an antipsychotic) and mirtazapine (an antidepressant) at therapeutic or low levels; d. Methylamphetamine (0.02mg/kg) at low levels; and e. Alcohol (121mg/100mL, equivalent to 0.121%). This indicates a moderate amount of alcohol had been consumed prior to death, with some of it having been metabolised.

13. 6 Mono-acetyl morphine (6-MAM) was also detected in Ms Richards’ urine, along with amphetamines, benzodiazepines and opiates.

14. Dr Forde commented that the presence of 6-MAM in Ms Richards’ urine indicated that heroin had been used prior to death (because 6-MAM is a metabolite exclusive to heroin). Substantial levels of total morphine, relative to free morphine indicated a period of delay to death, or the remains of recent prior ingestion.

15. Dr Forde commented that morphine is a central nervous system depressant, particularly affecting the respiratory centre. Alcohol is also a central nervous system depressant, along with benzodiazepines.

Concurrent use of these drugs and alcohol have an additive effect, leading to a more profound impaired conscious state and respiratory depression.

People with an impaired conscious state are unable to protect their airways and are prone to airway obstruction, both by positional means (for example, lying face down in bedding) or inhaling stomach or oral contents (aspiration). Dr Forde found evidence of some early aspiration change within Ms Richards’ lungs.

16. In Dr Forde’s opinion, the medical cause of Ms Richard’s death was: Findings of the inquest into the death of Karen Richards 3

1(a). Mixed drug and alcohol toxicity.

17. I accept Dr Forde’s opinion as to the medical cause of Ms Richard’s death.

The 000 phone call

18. Mr Angelo D'Amario phoned 000 from Ms Richards’ mobile phone at 11:36pm on 11 January 2014.

19. I obtained the recording of the 000 call, and it was transcribed by a staff member of the Coroners Court of Queensland for the purposes of the inquest.

20. During the phone call, Mr D'Amario was confused about his location. He initially said he was in Brighton and then he said he was in Sandgate, near Brighton. The 000 operator seems to have initially thought his location was Scarborough, and the address had to be clarified with Mr D'Amario several times throughout the call.

21. In the opening moments of the call, Mr D'Amario sounded calm and lacking in urgency. He said in a calm tone: ‘This cunt, this bitch could be dead, hey, please hurry’.

22. Mr D'Amario provided the following information to the 000 operator, as the call progressed: a. He had come over to visit his girlfriend. He popped over, he was running late; b. He called out, didn't hear a thing and she was already laying in bed; c. He laid beside her and cuddled her for about half an hour; d. About half an hour later, he moved his arm and felt a wet patch; e. He rolled her over. Her mouth was full of liquid or a vomit-type substance; f. He couldn't wake her up. He tried to give her mouth-to-mouth but more fluid came flying out; g. She wasn't breathing; h. He had just seen a syringe on the bed, whilst on the phone with the operator; i. She was starting to feel a little bit cold and she was going purple; j. Someone told him that she had started using drugs; k. He would do whatever it took. He didn’t want her to die. He ‘just met the girl’; and Findings of the inquest into the death of Karen Richards 4

l. He was there two nights ago and there were some guys there that ‘looked like fucking drug addicts’.

23. At the time Mr D'Amario made the 000 phone call, it would appear that Ms Richards was still lying on the bed. The operator instructed Mr D’Amario to place Ms Richards flat on the ground. The operator then instructed him to check her mouth for food and vomit, check her breathing, and commence CPR.

24. Mr D'Amario can be heard in the audio recording commencing CPR, and then vomiting part way through. It would appear from the recording that Mr D'Amario continually ceased chest compressions on Ms Richards and had to be repeatedly instructed by the 000 operator to keep going.

Attendance by the ambulance

25. The Queensland Ambulance Service has produced an ‘Electronic Ambulance Report Form’ (EARF), with a detailed case description and incident log.

26. The EARF indicates that the ambulance was enroute by 11:44pm on 11 January 2014 and arrived at the scene at 12:04am on 12 January 2014.

Their delayed arrival was due to an incorrect address of Scarborough being given to the ambulance crew, before it was later updated to Sandgate.

27. The first ambulance officer to arrive, Intensive Care Paramedic Catherine Hassall, provided a statement to police dated 18 August 2014. Paramedic Hassall stated that upon arrival, she found Ms Richards lying supine on the floor and Mr D'Amario was performing CPR.

28. Ms Richards was pale and there was nil rigour mortis. Ms Richards had a Glasgow Coma Scale 3 (the lowest possible score) and her presenting rhythm was asystole. She was unconscious, not breathing, and had no palpable pulse.

29. Paramedic Hassall stated that a history was difficult to obtain from Mr D'Amario because he was distressed. It was unknown how long Ms Richards had been unconscious.

30. Paramedic Hassall commenced resuscitation with two other colleagues who arrived at the scene soon afterwards.

31. Paramedic Hassall stated that during their resuscitation efforts, Mr D'Amario calmed down and provided the following information: a. He came home and found Ms Richards asleep; b. He hugged up to her; c. He awoke at about 10:40pm to find Ms Richards breathing abnormally; Findings of the inquest into the death of Karen Richards 5

d. Soon after, he noticed fluid around her head, possibly vomit and Ms Richards was unresponsive. Her breathing stopped shortly afterwards; e. He found a used needle in the bed next to her when he awoke; f. He did not commence CPR immediately; and g. He later commenced CPR and moved Ms Richards onto the bedroom floor.

32. Due to the history eventually provided by Mr D'Amario to the ambulance crew and the nil change in Ms Richards' presentation, Ms Richards was declared deceased by Paramedic Hassall at 12:22am on 12 January 2014.

33. The ambulance crew reported to the police upon their arrival that Ms Richards appeared to have been deceased for a few hours.

Attendance and investigation by the police

34. Senior Constable Matthew Ham and Senior Constable Renee Tugwell from the Sandgate Police Station were the first police officers to arrive at the scene at about 12:50am on 12 January 2014. Their supervisor, Sergeant Paul Rowling, soon joined them. At around 2:00am, Detective Senior Constable Jason Shea, Plain Clothes Senior Constable Michael Kerslake, and Senior Constable Sandra Rayleen from the Criminal Investigation Branch attended the scene and conducted a forensic investigation.

35. Mr D'Amario provided an oral version of events to Senior Constable Ham and Senior Constable Tugwell. The conversation was audio recorded by Senior Constable Ham and he made notes of the conversation in his official police notebook. The audio recording was transcribed, at my direction for the purposes of the inquest.

36. At the scene, police observed: a. A wet patch or pooling of fluid, which smelt of vomit, on the bed linen of the double bed where Ms Richards had been sleeping; b. A half empty wine glass on the lounge coffee table; c. Two empty casks of wine in the kitchen bin; d. Another full cask of wine in the refrigerator; e. Drug paraphernalia including a used syringe, alcohol swabs, a spoon, and a used needle sharps container on the bedside dressing table in Ms Richards' bedroom; f. A wooden box on the chest of drawers in Ms Richards' bedroom, Findings of the inquest into the death of Karen Richards 6

containing numerous forms of medication (all in Ms Richards' name); g. A box of 25 Diazepam tablets with 12 tablets missing. (The medication had been purchased on 11 January 2014 from the Malouf Pharmacy at Sandgate); h. Ms Richards was wearing underpants and a night/pajama top (which had been torn by the ambulance crew); i. Ms Richards smelt of vomit; j. The toilet smelt of vomit and there appeared to be clear/partially foamy vomit in the toilet bowl and on the floor around it; k. There were no visual injuries on Ms Richards or obvious signs indicative of a struggle or assault; and l. Ms Richards had numerous needle (track) marks on both of her inner arms (inside of both elbows),the top of her left hand, and the inner side of her right hand wrist.

37. Detective Senior Constable Shea formed the opinion that Ms Richards had undertaken recent intravenous drug use on the inside of her left elbow, owing to what appeared to be fresh scabbing at the needle injection site. Due to his observations of the injection sites, he formed the opinion that Ms Richards regularly injected drugs intravenously.

38. Police also located a notebook, which appeared to have been a journal kept by Ms Richards since 5 January 2014.

39. Police searched a silver Mercedes sedan, which was parked in Ms Richards' driveway. They located unlabeled pharmaceutical medication (Xanax), and a receipt on the front passenger seat for a needle sharps kit, which had been purchased at about 2:00pm on 11 January 2014 from the Malouf Pharmacy in Sandgate. They located a wallet with identification in the name of Mr D'Amario inside the vehicle and registration checks confirmed that the vehicle belonged to him.

40. Mr D'Amario provided the following information to police at the scene: a. He met Ms Richards in March 2013. At the time, Ms Richards was in a sexual relationship with his ex-girlfriend, Hannah. He met Ms Richards on one other occasion, and then in September 2013 they were both single and they ‘clicked’; b. Ms Richards was his girlfriend and they were in a sexual relationship.

She was the first girl he had really been with for four years and had ever felt comfortable with. They talked 20 times a day. They had just fallen in love; c. On 11 January 2014, he had received several phone calls from Ms Richards. That morning, she was pissed off more than usual due to Findings of the inquest into the death of Karen Richards 7

people asking her for money and dropping their problems on her; d. He had been out that day doing some shopping and he had visited a friend in Capalaba. After lunch, he spoke with Ms Richards on the mobile and he told her he was going to visit her at her home later that afternoon; e. He spoke with Ms Richards again on the mobile at around 3:00 - 4:00pm. She sounded drunk. She was slurring her speech and repeating herself. She was jealous because he had had coffee with someone else; f. He arrived at Ms Richard’s home at around dusk (when it was ‘night dark’) on 11 January 2014. He couldn’t recall the exact time. (Bureau of Meteorology records indicate that sunset for Brisbane that day was at 6:47pm); g. When he arrived, Ms Richards was drunk. He got in bed with her and ‘snuggled’ against her. She told him that she loved him and then they both fell asleep; h. At about 10:10pm, he woke up and went to the kitchen to get a drink of water. Ms Richards was snoring. He found a wet patch on the bed and thought she might have chocked on her vomit. He was shocked and tried to wake her by shaking her, but she was not moving. He felt for a pulse but was unable to locate one. He called 000 and began CPR. He moved Ms Richards from the bed to the floor; i. He denied having any knowledge that Ms Richards was an intravenous drug user. He said the first time he noticed the needle marks on Ms Richards’ arms was when she was with the ambulance.

He remarked: ‘No…stupid bitch that uses drugs. I let her get close to my daughter’; j. He claimed that he didn’t notice the needle sharps kit or the drug paraphernalia in Ms Richards’ room, which was in clear view; k. He denied buying the needle sharps kit, despite the receipt being found by police in his vehicle. He then said that he had passed out for about half an hour at the most at Ms Richards’ house and that she could have possibly used his car to go to the pharmacy to buy the needle sharps kit. He later said that he did go to the Sandgate Pharmacy that afternoon on his own to buy Ms Richards some black jellybeans to cheer her up. He suggested to the police that the Pharmacy attendant could have given him the wrong receipt; l. He said that he was aware that Ms Richards had been abusing prescription medication. About a month ago, he couldn’t get a hold of her. She phoned him the next day and said that her father had found her in the same sort of position on the bed and she was not breathing and he had raced her to the Redcliffe Hospital; Findings of the inquest into the death of Karen Richards 8

m. He said that he was aware that Ms Richards had mental health issues. She told him that she had been taking too much medication.

She medicated at night before she went to bed. He wasn’t sure whether she had taken any medication that night; n. He said that Ms Richards did not really abuse alcohol. She drank Chardonnay. They would have a drink every second or third night.

They would drink just one bottle between them; and o. Mr D’Amario said that he had ripped the label off his prescription medication in his vehicle so that he didn’t get confused between the different brands of pills that he had.

41. Police later obtained CCTV footage from the Sandgate Malouf Pharmacy, which shows a person matching Mr D'Amario’s description purchasing a needle sharps kit at around 2:00pm on 11 January 2014. The man in the CCTV footage was wearing the same black 'Abercrombie' shirt that Mr D'Amario was wearing at the scene. The needle sharps kit was packaged into a white paper bag similar to the bag observed on the vanity at Ms Richards’ dwelling. Police inquiries with the Malouf Pharmacy indicated that they used the white paper bag with the 'Ask your pharmacist' logo at the time.

42. The police noted that the version Mr D'Amario provided to them on the night of the incident was brief and disjointed. Mr D'Amario appeared to be suffering from profound grief, but on the other hand, he also appeared to be evasive and selective with his answers to their questions. Mr D’Amario admitted to being the owner of the silver Mercedes in the driveway but became hostile when questioned in relation to the receipt for the needle sharps kit located in his car. Mr D'Amario's mood appeared to police to swing between violent sobbing and wailing, crying out ‘Why?’ to becoming lucid and answering questions in a composed manner.

43. In the days following Ms Richards' death, police were unable to contact Mr D'Amario. He didn’t answer his phone or return messages. He was unable to be contacted at his last known residence, where police left several calling cards. After several weeks of leaving messages on his voice mail, Mr D'Amario answered his phone on 19 March 2014 and agreed to provide a statement to police the following day at the Carseldine Police Station.

44. On 20 March 2014, Mr D'Amario's solicitor, Mr Tim Meehan of Bosscher Lawyers, contacted Senior Constable Michael Kerslake and advised him that Mr D'Amario would provide a statement the next day. Then on 21 March 2014, Mr Meehan contacted Senior Constable Kerslake and advised him that Mr D'Amario would be exercising his right to silence and would no longer be supplying a statement to police.

45. Police door knocks conducted with Ms Richards' neighbours did not yield any information with respect to this matter.

46. A forensic examination of Ms Richards' mobile phone was conducted by Findings of the inquest into the death of Karen Richards 9

police via a Cellebrite device, which extracted certain SMS messages and phone call logs. Police noted that the SMS text messages indicated that Ms Richards was sourcing illicit drugs. They were of the opinion that the phone records indicated that Ms Richards may have been in relationships with at least three other male persons, besides Mr D'Amario, at the time of her death.

47. The police concluded that: a. It is highly probable that Mr D'Amario had knowledge of Ms Richards' drug use and that he was probably a drug user at the time; b. It is possible that Mr D'Amario brought the needle sharps kit to Ms Richards' residence and supplied her with a dangerous drug on 11 January 2014; c. If Mr D'Amario and Ms Richards were in a relationship, it is possible that they had both engaged in drug use together on the evening of Ms Richards' death; d. There were no suspicious circumstances surrounding Ms Richards' death; and e. Ms Richards’ death appears to have been a combination of alcohol and prescription/illicit drug use, and her fragile mental health state.

Ms Richards' medical history

48. Ms Richards’ medical records indicate that she had been diagnosed with a Borderline Personality Disorder. Her father stated that she was on a disability pension and had been receiving mental health treatment for over 10 years.

49. Ms Richards’ Pharmaceutical Benefits Scheme records indicated that in the 6 months leading up to Ms Richards’ death, she had been taking the following prescription medications: a. Pericyazine (usually for treatment of anxiety or tension and the maintenance or treatment of psychotic disorders such as schizophrenia); b. Diazepam (usually for treatment of a range of conditions such as anxiety); c. Mirtazapine (an antidepressant); d. Desvenlafaxine (an antidepressant); e. Methylphenidate (i.e. 'Ritalin', which is used for the treatment of attention deficit hyperactivity disorder and narcolepsy); f. Alprazolam (an antidepressant); and Findings of the inquest into the death of Karen Richards 10

g. Esomeprazole (to reduce stomach acid for the treatment of ulcers, etc.).

50. It would appear that Ms Richards had been ‘doctor shopping’. In the week leading up to her death, she filled scripts for Diazepam at three separate pharmacists on three different days: a. 1 box of 30 tablets on 3 January 2014 at the Simon Farr Pharmacy at Morayfield (prescribed by Dr Katayoon Javadi at Warner Medical Centre on the same day); b. 1 box of 25 tablets on 7 January 2014 at the Priceline Pharmacy at Strathpine (prescribed by Dr Rebecca Hargrave at the Brendale Medical Centre on the same day); and c. 1 box of 25 tablets on 11 January 2014 at the Malouf Pharmacy at Newstead (which appears to have been prescribed by Dr Johannes Scheepers at the Radius Medical Centre on 8 January 2014 but there was no record of this in Ms Richards’ Medicare records). This appears to have been picked up by Mr D'Amario between around 1:38pm and 1:59pm on 11 January 2014.

Ms Richards' journal entries

51. It would appear that Ms Richards began keeping a journal on her birthday, on 5 January 2014 (a week prior to her death).

52. The notebook obtained by the police contains several entries. The entries indicate that Ms Richards had a self-awareness of her mental illness and her drug abuse. She also appears to have had relationship difficulties with Mr D'Amario, her parents, and others who are unnamed.

53. Ms Richards made reference to Mr D'Amario in her journal entry dated 6 January 2014: Angelo hates my guts. Thinks I'm a you know what pig I think he is right as well my brain is wired different isn't it. I can't help it if other people can't handle shit they should have if you can't cope stuff them. I got really close to him and I just shut down turn off the person is vanished from my mind all of it another interesting thing and capability you get being borderline if I can't see you or hear you don't exist.

54. Ms Richards later mentioned Mr D'Amario again: ...I wonder what they think when I just disappear are they the same and switch off. I should ask Angelo. But he dislikes me now I'm a piglet and a taker apparently. So tough shit get stuffed think what you want. He's probably to wasted to know anyway.

55. Ms Richards also refers to her drug taking throughout her journal.

Examples include: a. In my speed induced mode I've texted one thousand messages to Findings of the inquest into the death of Karen Richards 11

dad; b. If you drop dead playing with fire you asked for it. You know the risks any drug is the devil in disguise; and c. ...I know I take drugs. I know it is bad. I know the devil. I know its bad. I know it will kill you....

Ms Richards' mobile phone records The following general information can be ascertained from Ms Richards' phone records: a. Ms Richards was in a volatile relationship with Mr Paul Ash, which appears to have ended by 24 September 2013; b. Ms Richards had moved on from her relationship with Mr Ash and had been in a relationship with a female, Hannah, prior to beginning a relationship with Mr Angelo D'Amario; c. At the time of her death, it would appear that Ms Richards was in a relationship with Mr D’Amario, ‘Wayne’, and ‘Jacko’.

a. Ms Richards' relationship with Wayne and Jacko were casual and amicable; b. Ms Richards had a friendship with 'Brian', who she considered had an alcohol and mental health problem. Brian appears to have stayed at Ms Richards’ house a number of nights leading up to her death, including the night before, on 10 January 2014; c. Ms Richards was in regular phone contact with her best friend, 'Reve'; d. Ms Richards had a volatile relationship with her father. She did not tell her father the full story about her drug usage or relationships; e. Ms Richards had a number of serious arguments with Mr D'Amario in the week leading up to her death. She had him listed in her mobile phone contact list as ‘Demon Possessed’. At one stage, she threatened to kill Mr D'Amario. However, she also made it clear that she still cared for Mr D'Amario's daughter; f. Ms Richards usually obtained drugs from 'Janie' but she did not appear to have been happy with the quality of the drugs, so she had been sourcing them from Mr D’Amario in the days leading up to her death; and g. Ms Richards claimed to have had links with ‘bikies’ - namely the Rebels and Mongols.

Ms Richards' phone contact on the day of her death

56. When Ms Richards' incoming and outgoing phone calls are combined with Findings of the inquest into the death of Karen Richards 12

her text messages on the day of her death (11 January 2014), they reveal a great deal about her frame of mind and what was going on that day. I have therefore set out the full sequence below: a. 2:37am: Ms Richards tried to call her friend, Mr Brian Alderwick, but he didn't answer; b. 2:38:08am: Ms Richards texted Mr Alderwick: Sorry for being rude I was pissed as I'm a bit ill too; c. 2:38:29am: Ms Richards texted Mr Alderwick: Just need some help; d. 2:51am: Ms Richards texted Mr Alderwick: And I was upset u went off with Janie out bec(ause) we agreed we got ripped off ect I didn't get it; e. 2:53am: Ms Richards phoned Mr Alderwick but either got his answering machine or had a very quick conversation (phone call duration: 21 seconds); f. 3:01am: Ms Richards texted Mr D'Amario: What happened to you last night anyway just got attacked by guy next door police here I tried to ring u u turned yr ph off I needed to get out of here; g. 3:09am: Ms Richards tried to phone Mr Alderwick but either got his answering machine or had a very quick conversation (phone call duration: 27 seconds); h. 3:11am: Ms Richards tried to phone Mr D'Amario but he didn't answer; i. 3:12am: Ms Richards texted Mr D'Amario: You know what I just don't get people; j. 3:21am: Ms Richards texted Mr Alderwick: Doesn't matter I like janie too tried to ring u patrick attacked me whatever hey I look after myself; k. 3:22am: Ms Richards texted her drug dealer, Ms Janie Palmer: Sorry to bother u got attacked by guy next door need a u knw what want to kill it; l. 3:24am: Ms Richards texted Ms Palmer: Also he is a pedophile he told me a 12 year old he got onto I'm going off; m. 3:27am: Ms Richards texted Mr Alderwick: I don't even knw if u read this shit; n. 3:27am: Ms Richards texted Mr Alderwick: Whatever tried to ring for help; o. 3:45am: Ms Richards texted Ms Palmer: Sorry for bothering u just Findings of the inquest into the death of Karen Richards 13

smashed the shit out of him got arrested he is a mess; p. 4:50am: Ms Richards tried to phone Mr D'Amario but he didn't answer; q. 7:25am: Ms Richards phoned Mr Alderwick and they had a 22 minute conversation; r. 8:16am: Ms Richards phoned Ms Palmer and they had a 1:52 minute conversation; s. 9:20am: Mr Alderwick sent Ms Richards a blank text message; t. 9:37am: Ms Richards received a text message from her best friend, Ms Reve Scott: Morning ling xxx; u. 9:54am: Ms Richards tried to phone Mr D'Amario but he didn't answer; v. 9:59am: Mr D'Amario tried returning Ms Richards’ phone call but it went through to her message bank. He did not leave a message; w. 10:08am: Ms Richards texted Ms Scott: Morning bub; x. 10:15am: Ms Richards phoned Mr D'Amario and they had a 2:58 minute conversation; y. 10:24am: Ms Richards tried to phone Mr D'Amario and he didn't answer; z. 10:25am: Ms Richards received a text message from Ms Scott: How's it all going?; aa. 10:27:04am: Ms Richards texted Ms Scott: I talked to him about it straight he doesn't remember a thing but I'm ok; bb. 10:27:35am: Ms Richards received a text from Ms Scott: Ok well hopefully he gets the message; cc. 10:28:14am: Ms Richards texted Ms Scott: He sis I was very me said it straight; dd. 10:28am: Ms Richards phoned Mr D'Amario and they had a 3:44 minute conversation; ee. 10:30am: Ms Richards received a text from Ms Scott: Cool well what you up to; ff. 10:33am: Ms Richards texted Ms Scott: Brian just left I'm home alone; gg. 10:34am: Ms Richards received a text from Ms Scott: Ok well maybe Findings of the inquest into the death of Karen Richards 14

go to your mums for the weekend; hh. 10:35:00am: Ms Richards texted Ms Scott: No way she is like my enemy I'm happy like this; ii. 10:35:18am: Ms Richards texted Ms Scott: I don't need anyone; jj. 10:35:26am: Ms Richards received a text from Ms Scott: Yeh i just mean with the neighbour; kk. 10:35:38am: Ms Richards texted Ms Scott: No its ok; ll. 10:35:55am: Ms Richards texted Ms Scott: This is my home; mm. 10:36:04am: Ms Richards received a text from Ms Scott: Be careful; nn. 10:36:17am: Ms Richards texted Ms Scott: Yep iam now oo. 10:36:43am: Ms Richards received a text from Ms Scott: Ok all good; pp. 10:36:57am: Ms Richards texted Ms Scott: Yep I'm fine hub; qq. 10:37:16am: Ms Richards received a text from Ms Scott: I'm watching american horror story 2 about an asylum its full on; rr. 10:37:35am: Ms Richards texted Ms Scott: Oh I want to see it; ss. 10:37:56am: Ms Richards received a text from Ms Scott: Its pretty horrible; tt. 10:38:04am: Ms Richards texted Ms Scott: Cool lol; uu. 10:38:38am: Ms Richards received a text from Ms Scott: Hmmm I don't know if i would call it cool its sad; vv. 10:39:02am: Ms Richards texted Ms Scott: Really don't watch it pop; ww. 10:39am: Ms Richards phoned Mr D'Amario and they had a 16:01 minute conversation; xx. 10:40am: Ms Richards received a text from Ms Scott: No its ok it interests me to do with work and how people were treated back then; yy. 10:56:17am: Ms Richards would have just gotten off the phone with Mr D'Amario and then texted Ms Scott: Yeah I get it; zz. 10:56:46am: Ms Richards received a text from Ms Scott: Yeh its made up though; aaa. 10:57am: Ms Richards texted Ms Scott: Yeah; bbb. 10:58am: Ms Richards texted Mr D’Amario: I rang terri we are ok and Findings of the inquest into the death of Karen Richards 15

rebels and mongols u are ok; ccc. 10:59:25am: Ms Richards received a text from Ms Scott: But sad interesting; ddd. 10:59:45am: Ms Richards texted Ms Scott: Yeah totally; eee. 10:59:47am: Ms Richards received a text from Mr D'Amario: Tnx; fff. 11:00:07am: Ms Richards received a text from Ms Scott: Yeh; ggg. 11:00:21am: Ms Richards texted Mr D'Amario: It's fine you have too many people hhh. 11:02am: Ms Richards texted Mr D'Amario: Mongels asked do u want them now but u hv to be at my house; iii. 11:05am: Ms Richards attempted to phone Mr D'Amario but he didn't answer; jjj. 11:06am: Ms Richards texted Mr D'Amario: They want numbers; kkk. 11:07am: Ms Richards tried to phone Mr D'Amario but he didn't answer; lll. 11:09am: Ms Richards texted Mr D'Amario: If you want help answer ph terri is wanting things; mmm. 11:12am: Ms Richards tried to phone Mr D'Amario but he didn't answer; nnn. 11:14am: Ms Richards texted Mr D'Amario: Answer ph these people are onto it if I don't knw addresses ph numbers they are over it; ooo. 11:15am: Ms Richards texted Mr D'Amario: You hv 76 bikies and mafia doing u a favour; ppp. 11:20am: Mr D'Amario phoned Ms Richards and they had a 11:14 minute conversation; qqq. 11:22am: Ms Richards received a text from 'Jacko': THINKING OF

U HOPE U R WELL CAN'T WAIT TO SE U THINKING OF YOU ALWAYS XXXOO; rrr. 11:28am: Ms Richards texted 'Jacko': Thank u x; sss. 11:29am: Ms Richards texted Mr D'Amario: Better forget mum these people want the lot; ttt. 11:32am: Mr Alderwick phoned Ms Richards and they had a 11:14 minute conversation; Findings of the inquest into the death of Karen Richards 16

uuu. 11:34am: Ms Richards received a text from 'Jacko': CAN'T Witto c u and finally move. IT A SAIN HOUSE IHAVE NO WHERE. ELS

TOGOIT WILL WERKOUT JUST FINE; vvv. 11:43am: Ms Richards received a text from 'Jacko': WHERE R. U.?; www. 11:59:04am: Ms Richards phoned Mr D'Amario and she either got his answering machine or they had a very short conversation of 11 seconds; xxx. 11:59:55am: Ms Richards tried to phone Mr D'Amario but he didn't answer; yyy. 12:01pm: Mr D'Amario phoned Ms Richards and they had a 55 second conversation; zzz. 12:07pm: Ms Richards tried to phone Mr D'Amario but he didn't answer; aaaa. 12:08pm: Ms Richards phoned Mr D'Amario and they had a 4:17 minute conversation; bbbb. 12:15:30pm: Ms Richards tried to phone a medical practice but the phone call was either not answered or did not go through; cccc. 12:15:44pm: Ms Richards tried to phone Mr D'Amario but he didn't answer; dddd. 1:10pm: Ms Richards phoned Mr D'Amario and they had a 4:28 minute conversation; eeee. 1:51pm: Ms Richards phoned Mr D'Amario and they had a 3:10 minute conversation.

ffff. 2:56:04pm: Ms Richards phoned an unknown number, but there was no answer; gggg. 2:56:38pm: Ms Richards phoned an unknown number (which was an incorrect phone number due to the number of digits); hhhh. 2:57pm: Ms Richards phoned an unknown number, and either got an answering machine or hung up shortly after as the duration was 7 seconds; iiii. 4:46pm: Ms Richards received a text from ‘Wayne’: Hello Miss whatya up to; and jjjj. 5:30pm: Ms Richards received a text from an unknown number that she had previously tried to phone: Who dis.

57. I note that phone contact ceased with Mr D’Amario at around 1:54pm and there was no phone activity at all after 5:30pm (with the exception of the Findings of the inquest into the death of Karen Richards 17

phone call that Mr D’Amario made to Ms Richards’ phone at 11:44pm).

Mr Paul Richards’ evidence

58. Mr Paul Richards is Ms Karen Richards’ father. He provided two statements to the police dated 18 September 2016 and 25 November 2016.

59. Mr Richards stated that his daughter had been seeing psychiatrists since her late teens. She had been diagnosed with Borderline Personality Disorder.

60. Ms Richards had been seeing Dr Morris at Pine Rivers Private Hospital from early 2010 until mid 2013. Dr Morris was very careful in what he prescribed Ms Richards and was strict with her. Dr Morris also kept Mr Richards well informed.

61. Dr Morris tried Ms Richards on a short course of Concerta, which Mr Richards later realised was like a prescribed ‘speed’. He was told by Dr Morris that this was an ADHD treatment. Ms Richards was also referred to the Radius Medical Centre for Ketamine treatment.

62. Mr Richards stated that was when it all went ‘off the rails’ in relation to his daughter’s medical treatment. Ms Richards was being looked after by a Psychiatrist, Dr Scheepers, but she was seeing a range of medical practitioners, who were mostly GPs, at the Radius Medical Centre. He went in to personally see Dr Scheepers to express his concerns about Concerta and to advise that he felt Ms Richards was misusing the drug and abusing herself with it. He also left strict instructions on another occasion with Dr Scheeper’s secretary when he could not speak with Dr Scheepers, to ensure his daughter was no longer prescribed Concerta.

He later found out that a GP from the Radius Medical Centre had nevertheless prescribed the drug to his daughter and that she had overdosed on it.

63. Mr Richards stated that in early September 2013, his daughter informed him that she had previously used heroin. She told him that two people named Angelo (i.e. Mr D’Amario) and Hannah had injected her with it the first time she used it, when she met them in May 2013. She told him that Mr D’Amario had recently used heroin again with her. She said that she hated needles and could never inject herself and would never touch heroin again.

64. Mr Richards met Hannah once but he had never met Mr D’Amario. He stated that his daughter had mentioned Mr D’Amario several times.

However, she did not mention him in a loving way, or anything that sounded like a romantic interest. It sounded to him more like Mr D’Amario was an acquaintance.

65. Mr Richards stated that his daughter had ended up in hospital on the morning of 8 January 2014.

66. Mr D’Amario stated that he saw, after his daughter’s death that Mr Findings of the inquest into the death of Karen Richards 18

D’Amario drove a Mercedes Benz sports car and he had been told by Mr Paul Ash and Mr Brian Alderwick that Mr D’Amario was a drug dealer.

67. Mr Richards did not know or suspect that his daughter had any actual links with Criminal Motorcycle Gangs (bikies).

68. On 14 January 2014, Mr Richards wanted to talk to Mr D’Amario about his daughter’s death and to get the keys to her unit from him. He stated that Constable Matthew Ham said it was okay to do so. He phoned Mr D’Amario on the phone number listed in his daughter’s mobile phone and they made arrangements for him to attend Mr D’Amario’s mother’s residence. He later attended the residence with his son.

69. Mr Richards stated that when he spoke with Mr D’Amario about his daughter’s death, Mr D’Amario broke down crying. He told Mr Richards that he had arrived at Ms Richards’ place in the late afternoon (on 11 January 2014) as she had asked him over for dinner and she was going to make Mexican tacos. Mr D’Amario said that Ms Richards was in no fit state to make dinner as she had been drinking. He said that late in the night she was attacking herself with a syringe and plunging it into her arm and hand. After all of this, he fell asleep and awoke to find Ms Richards not moving on the bed beside him. He said that Ms Richards had horrible vomit and liquid from her mouth all over herself and the bed. His reaction was to run to the toilet and he projectile vomited into the bowl.

70. After Mr D’Amario claimed in oral evidence during the inquest that he slept in the spare room on the night of Ms Richards’ death, Mr Richards confirmed in an email to the Coroners Court that his daughter did not have a spare room to sleep in at her apartment. The spare room was packed with gym equipment and other items.

71. I found that Mr Richards’ evidence was credible and reliable. He attended for the duration of the first phase of the inquest. However, I saw no need to call him as a witness at the inquest due to his detailed statements and the distress that his daughter’s death had caused him.

Mr Paul Ash’s evidence

72. Mr Paul Ash provided a statement to the police dated 25 October 2016 and oral evidence at the inquest.

73. Mr Ash stated that he first dated Ms Richards in 2003 or 2004 for six months. By the end of the relationship he realised that Ms Richards had mental health issues. She was addicted to anti-depressants, she abused alcohol, and she had been giving her medication to others.

74. Mr Ash stated that they began dating again in January 2013 for around eight months. Ms Richards had begun attending church with him and they were establishing a family unit with his young daughter.

75. Early on in their (second) relationship, Ms Richards admitted to having sex with Hannah and Mr D’Amario when she had not yet committed to a monogamous relationship. She had also admitted to taking heroin, which Findings of the inquest into the death of Karen Richards 19

she got from Mr D’Amario. She promised that it would not happen again.

She explained that she had been drawn into this past ‘love triangle’, with Hannah and Mr D’Amario through drugs but that she had escaped it.

76. Mr Ash proposed to Ms Richards in around mid 2013 and they were engaged to be married. It was at this time that Ms Richards re-established a relationship with Hannah and Mr D’Amario. Mr Ash stated that Ms Richards would return from visiting them in a scattered state and she seemed exhausted and drug affected.

77. In relation to her prescription drug usage, Mr Ash stated that it became evident to him that Ms Richards was now addicted to a new series of medications with which she played a dangerous balancing act. There were the antipsychotics, which made her dopey, dexamphetamine to pick her up, and Stilnox to get her to sleep. He was aware that she took medication to help her sleep often. She was taking the sleeping medication because the dexamphetamine kept her awake.

78. It appeared to Mr Ash that Ms Richards had been trading her dexamphetamine prescription drugs for heroin because she was always coming back without her prescription dexamphetamine. At one stage she had allegedly lost a quantity of the dexamphetamine prescription drugs.

She never used the term ‘trade’ but she had said to Mr Ash that she would share her dexamphetamine prescription drugs with Hannah and Mr D’Amario. Mr Ash also stated that Ms Richards told him that Mr D’Amario had supplied her with Valium once or twice.

79. Mr Ash started to become suspicious and he monitored Ms Richards’ text messages. He stated that he saw text messages between Ms Richards, Hannah, and Mr D’Amario referring to ‘Heather’, which Ms Richards later told him was in reference to heroin.

80. Mr Ash stated that they had a bbq at their house one evening. There were about four or five people in attendance, including Mr D’Amario. Hannah was not in attendance. The next morning, he found used syringes (capped) in the kitchen. Ms Richards admitted that she had used heroin the night before with Mr D’Amario. She said that she only used heroin with Mr D’Amario.

81. Mr Ash was of the understanding that Ms Richards had no need for ‘speed’ because of the dexamphetamine prescription drugs, which she seemed to have an endless supply of. Mr Ash stated that he caught Ms Richards with her friend, Mr Brian Alderwick, a couple of times having what they called ‘dexy parties’ at Ms Richards’ house. They were ‘both jumping around and yapping away’. He did not think that Mr Alderwick was linked with Mr D’Amario.

82. Mr Ash also observed that Ms Richards liked to ‘play people off against each other’ and was ‘attention seeking’. She was also ‘manipulative’. He also stated that ‘she was a very beautiful person and enjoyed the attention of men’. However, Ms Richards had never expressed any attraction to Mr D’Amario. She referred to him as a friend.

Findings of the inquest into the death of Karen Richards 20

83. Ms Richards never mentioned bikies that Mr Ash could recall.

84. I found that Mr Ash provided open, honest and reliable evidence.

Ms Reve Scott’s evidence

85. Ms Reve Scott provided a statement to the police dated 15 June 2016 and oral evidence at the inquest.

86. Ms Scott stated that she met Ms Richards in around 2001. They would talk on the phone and go to the same parties. They were inseparable right up to the time she died. They would talk on the phone nearly every day and text each other.

87. Ms Richards was pretty popular and she had a lot of friends that struggled with drug and alcohol abuse. She had a big heart and she tried to help people out.

88. Ms Scott stated that Ms Richards told her that she used speed and smoked pot when she was younger but that it didn’t agree with her. She recalled that Ms Richards was taking Valium as well as other antidepressants. She would take codeine a lot, stating that she had a sore neck. She was on a lot of prescription drugs, including a drug called Concerta, which is a slow release drug for ADHD. She thinks Ms Richards started taking this about six months before her death.

89. Ms Scott stated that for a few years before she died, Ms Richards would phone her and tell her that she wanted to end her life and she would send her goodbye texts.

90. Ms Scott stated that Ms Richards was in and out of the Pine Rivers Private Mental Health Ward in Strathpine in the two to three years before she died. Her mental health really deteriorated during this time. She told her about different people that she would be in the ward with. She thinks some of those people had links with bikies. She stated that Ms Richards seemed to have an obsession with bikies. She would read books about bikies and she told her that she lived with the Hells Angels bikies around the Wavell Heights area when she was younger, before they met.

91. Ms Scott stated that about six months before Ms Richards’ death (i.e. mid 2013), she told her that she had tried heroin but that she didn’t like it and she felt guilty about being a drug addict. She said that she used heroin with Hannah. She sometimes mentioned Mr D’Amario. Ms Scott’s understanding was that Mr D’Amario was Hannah’s ex-boyfriend.

92. I found that Ms Scott provided open, honest and reliable evidence.

Mr Patrick Mullice’s evidence

93. Mr Patrick Mullice provided a statement to the police dated 10 October 2016 and oral evidence at the inquest.

94. Mr Mullice was Ms Richards’ neighbour and friend. He stated that he first Findings of the inquest into the death of Karen Richards 21

met her around August 2013 when she moved in next to him. They would talk regularly across their balconies and he would visit Ms Richards every few days.

95. Mr Mullice stated that Ms Richards mentioned to him a few times that she got her drugs from her boyfriend, Mr D’Amario. He could not recall whether she was referring to prescription or non-prescription drugs.

96. Mr Mullice would often see Mr D’Amario’s car, a silver Mercedes, parked in the driveway. Mr D’Amario would visit Ms Richards at any time of the day or night and for extended periods of time. There were nights when Mr D’Amario would stay. His understanding was that Ms Richards and Mr D’Amario were ‘quite an item’. ‘They were lovers’. Ms Richards would refer to Mr D’Amario as her ‘boyfriend’. She had also introduced him to Mr D’Amario and he had met Mr D’Amario a few times.

97. Around the time of Ms Richards’ death, Mr Mullice noticed that she seemed to be drinking more. He would drop around to her house and she would suggest that they go to the bottle shop and buy some wine. They would go back to her place and Ms Richards would drink. On one occasion Mr Mullice drank with her and had a few too many but he would usually abstain from drinking.

98. Mr Mullice stated that Ms Richards was always very talkative and alert but around the time of her death, he noticed that she looked very tired and perhaps hungover. He stated that he never witnessed Ms Richards taking drugs.

99. Mr Mullice stated that he was not involved in any altercation with Ms Richards at or around the time she died. He did tell Ms Richards to ‘shut up’ on one occasion to let him get a word in but they were still good friends.

100. I found that Mr Mullice provided open, honest and reliable evidence.

Mr Brian Alderwick’s evidence

101. Mr Brian Alderwick provided a statement to the police dated 19 October 2016 and oral evidence at the inquest. Mr Alderwick’s memory was limited due to his mental health condition, history of alcohol abuse, and the time that had passed.

102. Mr Alderwick stated that he had known Ms Richards for around three years before her death. They were friends, ‘like brother and sister’. They had met at the Strathpine Private Hospital when he was admitted due to his alcohol problems.

103. He would see Ms Richards every week or two. They lived about 20 minutes drive from each other and would visit each other. When Ms Richards’ car ‘blew up’, he would drive her around sometimes.

104. Mr Alderwick stated that when he slept over at Ms Richards’ house, he would sleep on the couch. He thought there was a gym or junk room but there was no bed in there. The only sleeping options were Ms Richards’ Findings of the inquest into the death of Karen Richards 22

bed or the couch.

105. Mr Alderwick stated that he saw Ms Richards use heroin once. No one else was there and as far as he knew, she had injected herself. He stated that she had started to fall asleep, so he took her for a walk.

106. Mr Alderwick stated that Ms Richards once gave him the drug ‘Ice’.

107. Mr Alderwick didn’t recall staying at Ms Richards’ house the night before her death or visiting her the morning of her death but he conceded that it was possible.

108. Mr Alderwick stated that if he were trying to source drugs on 9 January 2014 through Ms Richards from Mr D’Amario or others, he would have been trying to get Valium. He stated that he could not recall Ms Richards mentioning heroin. He wasn’t a heroin user. He could not recall whether Mr D’Amario provided them with drugs at the time.

109. Mr Alderwick stated that he had become friends with Ms Janie Palmer after Ms Richards’ death. He stated that Ms Palmer did not deal in heroin to his knowledge.

110. Mr Alderwick stated that he had met Mr D’Amario. He wouldn’t say that he was Ms Richards’ ‘boyfriend’. He was a ‘strange one’.

111. I found that Mr Alderwick provided honest evidence. His evidence can be relied upon in a general sense but only limited weight can be placed on some of the detail, due to his memory issues.

Ms Janie Sue Palmer’s evidence

112. Ms Janie Palmer provided a statement to the police dated 16 November 2016 and oral evidence at the inquest.

113. Ms Palmer stated that she was a drug user in the past but at the time that she provided evidence at the inquest she had just gotten out of rehab and was not using. She had used speed and Valium but nothing else. She had been able to acquire speed and sell it to others in the past.

114. Ms Palmer stated that she only knew Ms Richards for a couple of months prior to her death. They met late in 2013 and they met through Mr D’Amario. She had met Mr D’Amario through another person in the context of drugs.

115. Ms Palmer stated that from the moment she met Mr D’Amario, she thought he was a ‘bit shady’. He had ‘ulterior motives’. He would always try and manipulate a situation for his own benefit. He had a Mercedes and he tried to use his car to influence people. He would try and make out that he was a big person because of where he worked. He tried to make out that he was someone that he wasn’t.

116. Ms Palmer agreed that Mr D’Amario was probably a drug dealer, although he never seemed to have anything when she asked him. She described Findings of the inquest into the death of Karen Richards 23

him as a ‘middle man’. She never saw him deal drugs but she noticed when she was around Mr D’Amario, people would come over for a short time and leave. She chose not to know what was going on. She had ‘heard along the grapevine’ that Mr D’Amario had heroin but she had never seen this.

117. She stated that she only saw Ms Richards a couple of times. They were not friends. When she first met Ms Richards at Mr D’Amario’s house in Carindale, Ms Richards was upset and crying and Mr D’Amario was talking to her. Mr D’Amario appeared to be looking after her. Her impression was that Mr D’Amario and Ms Richards were boyfriend and girlfriend. They were spending a lot of time together. Ms Richards had her clothes at his house and they were sharing the bed. Whenever Ms Richards had dramas, she would go to Mr D’Amario. She used to send him text messages and Mr D’Amario would answer them. She didn’t think Ms Richards had any money. It also looked like Ms Richards was taking care of Mr D’Amario and his daughter.

118. Ms Palmer stated that the couple of times she met Ms Richards was in relation to the drug, ‘speed’. They did speed together and she would meet Ms Richards at an address in Bowen Hills. Ms Richards would text or phone Ms Palmer and she would sell Ms Richards speed.

119. On one occasion at Mr D’Amario’s house, Ms Palmer stated that she mixed up the speed for Ms Richards, Mr D’Amario and herself. Ms Palmer injected herself in the bathroom, whilst Ms Richards and Mr D’Amario were in the bedroom together. She did not see either of them take the drug. The options for taking speed were to inject, smoke, snort or eat it.

120. Ms Palmer stated that she only ever sold Ms Richards speed but she was aware that Ms Richards also smoked ‘pot’ as she had seen her smoking it once.

121. Ms Palmer stated that she was not aware whether Ms Richards had anything to do with bikies.

122. Ms Palmer stated that she had met Mr Brian Alderwick through Ms Richards. He did speed, alcohol, and he was on prescription medication (namely Valium). Ms Richards had gotten the drugs for him.

123. Ms Palmer stated that she had never been to Ms Richards’ house in Sandgate. If Ms Richards had been trying to acquire drugs from her on 9 January 2014 (two days before her death), she would have had to go to Ms Palmer’s house. Ms Palmer stated that she did not deal heroin; she would only have dealt speed.

124. Ms Palmer stated that after Ms Richards’ death, Mr D’Amario phoned her and advised her that Ms Richards was dead. She was not sure why he rang her because she didn’t really know Ms Richards. The conversation was short. Mr D’Amario mentioned to her that Ms Richards’ father had phoned him. Mr D’Amario seemed to be ‘over explaining’ himself and trying to ‘throw the blame onto someone else’. ‘It was like he was trying to Findings of the inquest into the death of Karen Richards 24

say he had no involvement with [her death] whatsoever’.

125. I found that Ms Palmer was hesitant at times when providing her evidence due to her concern about self-incrimination, but once she was granted privilege, she gave open and honest evidence. She was a reliable witness.

Mr Angelo D’Amario’s oral evidence

126. Mr D’Amario provided the following relevant oral evidence at the inquest: a. He had been in an ‘open’ sexual relationship with Ms Hannah Ross for about 12 months until around late 2012. It wasn’t the ‘closest of relationships’ and they weren’t ‘madly in love’. They were ‘on again off again’. (Our investigations revealed that Ms Ross also died from mixed drug toxicity on 5 February 2016); b. He first met Ms Richards at Hannah’s house in early 2013, when he was still in a relationship with Hannah. Hannah and Ms Richards were in a sexual relationship together but he did not participate; c. He had known Ms Richards for about 12 months before she died.

They were ‘just friends’. They were not in a sexual relationship. They would only see each other once or twice a month or every second month. He would have only stayed the night at Ms Richards’ house two to three times over the 12 months; d. Hannah was a heroin user. He initially stated that he saw her use heroin once or twice. He later stated that he was never present when Hannah used Heroin; e. He wasn’t sure where Hannah obtained the heroin. He was not a drug dealer and had never obtained or dealt heroin; f. He initially stated that he had never used heroin. It was not something that appealed to him. He later stated that he had tried heroin once about four or five years ago (i.e. 2012/2013). He stated he didn’t like it, it was ‘rather disgusting’; g. Ms Richards was not a heroin user to his knowledge; h. He used marijuana and speed. He had been a speed user for about 10 years but was no longer using. He would inject speed or take it orally; i. He initially stated that he had never given speed to Ms Richards. He later stated that Ms Richards had obtained speed from him in the past. They had ‘shared it’. This began around mid 2013 but they only ever did it a few times; j. He injected speed himself. He did not inject Ms Richards. He was not sure how she used it. It’s always been a ‘pretty private thing’ for him. He was not a ‘group user’; Findings of the inquest into the death of Karen Richards 25

k. He would purchase his own needles and needle sharps containers from the pharmacy and then dispose of them in the container provided and return it to the pharmacy; l. He knew Ms Janie Palmer. She was seeing a friend of his at the time.

He had only met her about three times. The circumstances of him meeting her was not drug related. He never obtained drugs from, or used drugs with Ms Palmer. He wouldn’t know whether Ms Palmer was a drug dealer. He stated that if Ms Palmer and Ms Richards were doing drugs at his house, he wasn’t there; m. He denied phoning Ms Palmer to inform her that Ms Richards had died; n. He denied ever sharing a bed with Ms Richards. He stated that he allowed her to stay in his room at one point because it had an ensuite for her privacy. He later stated that he thinks he shared a bed with Ms Richards one night but they weren’t in a sexual relationship; o. On 11 January 2014, he had been in contact with Ms Richards most of the day. He stated that Ms Richards had invited him to her house for lunch. He was supposed to be there at about 12:00/1:00pm.

However, he was running late because he had some errands to run with his elderly parents who were in their 80s. They resided in Mt Gravatt. When he had finished running his mother around, his father decided that he wanted to do a few things such as go to the bottle shop, the TAB, etc. This dragged on until mid afternoon. Ms Richards had been asking him why he was running so late. He ended up arriving at Ms Richard’s house at around 4:00/5:00pm; p. He accepted that the person in the CCTV footage at the Sandgate Pharmacy on 11 January 2014 was him. The CCTV footage had him leaving the pharmacy at about 1:38pm. However, the timing on the receipt for the sharps kit purchased had a time of 1:59pm; q. Mr D’Amario stated that he would probably have made his way to Ms Richard’s house directly from the pharmacy on 11 January 2014.

He accepted that given Ms Richards’ house was only around a 15 to 20 minute drive from the pharmacy, he would have arrived at Ms Richards’ house between 2:00 – 3:00pm (accounting for the possibility that the timing on the CCTV footage and the receipt were slightly out). However, he didn’t remember arriving at Ms Richards’ house that early; r. He stated that when he arrived at Ms Richards’ house on the afternoon of 11 January 2014, she was ‘rather upset’ with him. She had voiced her opinion about how lunch had gone cold and that he had promised to be there by lunch. He had assumed that she’d had a few drinks by then. He had a headache and he didn’t really feel like listening at the time, so he ‘pretty much’ went to sleep ‘straight away’; Findings of the inquest into the death of Karen Richards 26

s. He couldn’t remember if Ms Richards was standing up or sitting down when she was talking to him. He did not see her take any drugs. She appeared to be more drunk than usual. She was ‘slurring, sitting there, holding her glass’. The language wasn’t the nicest. He had had a big day and a big week himself. He went and had a sleep in the spare room. He ‘crashed out pretty solid’; t. He then woke up in the late hours of the night, he thinks around 11:00pm. When asked what made him think that it was 11:00pm, he stated that he ‘must have looked at a clock or something and saw that it was 11’. He went out to the kitchen to get a cigarette and to have a drink. He noticed that both a pouch of tobacco and a packet of cigarettes had been smoked. He couldn’t find a clean glass. The house was pretty untidy, which wasn’t really Ms Richards because she was ‘pretty fastidious around the house’. He noticed his car keys had been moved. He went to see if he could find a cigarette in Ms Richards’ room when he found her lying in an unusual position. She was lying on the bed diagonally, belly and face down. Her palms were up and her feet and legs were hanging off the edge of the bed; u. He tried calling out to Ms Richards to wake her up to see if there were any cigarettes there but just seeing her like that ‘didn’t seem right’. He tried calling again, and then a little louder. He approached her to shake her a bit to see if she would wake up. There was no response. So he shook her a little more and tried to call out to her a little louder. He went to turn her head over and he noticed that fluid had just flowed from her mouth. ‘It just didn’t seem right’. He was a ‘little worried’. He called her name out again and tried to wake her up again and then ‘just instantly called 000’; v. The first time he administered CPR was under instruction from the 000 operator; w. He did his best to remain calm when speaking with the 000 operator; x. After the 000 audio recording was played for Mr D’Amario in court, he conceded that he advised the operator that he had laid down beside Ms Richards to give her a cuddle and felt something wet. He then stated that he probably did lie beside Ms Richards. He thinks he was getting on the bed and felt the wet. He stated that he didn’t want to get into a lengthy and pointless discussion with the 000 operator. He probably jumped from point to point to get on with the real matter. He then denied that he ‘cuddled’ or ‘snuggled’ Ms Richards that night, but he stated that he had cuddled her one night in the past; y. He later conceded that the ambulance record, which stated that he said he had ‘hugged up’ to Ms Richards, was possibly more correct than his recollection in court. He stated that he cuddled up to Ms Richards because it was ‘perhaps a nicer way of waking up...rather than having someone screaming at a door to a person to wake up’; Findings of the inquest into the death of Karen Richards 27

z. He denied sharing a bed with Ms Richards on the night she died. He conceded that he said to the 000 operator that Ms Richards was his girlfriend but he stated that he used it as a ‘layman’s term’. He had referred to Ms Richards as his girlfriend because he had gotten to know her as an ‘acquaintance’ or a ‘female friend’; aa. He denied referring to Ms Richards as a ‘cunt’, as indicated in the audio recording and transcript of the 000 call. He stated that was not a word that he used in his vocab. He stated that it may have sounded like that and he may have been trying to say something else and cut it short by saying ‘but this bitch could be dead’. He stated that he said: ‘this bitch could be dead’ to try to hurry the operator along. He explained that the operator was trying to get him to find a phone number that he couldn’t get access to. He had flat batteries. He couldn’t find a charger. He had a new number himself. He was trying to remain calm as well. ‘They took all that time to try and find a number’. Whereas, his ‘urgency was in trying to keep calm and to get an ambulance there’; bb. He conceded that he advised the 000 operator that he had ‘just met the girl’ when he had in fact known Ms Richards for 12 months. He stated that he had just come across a ‘friend like that’ and he probably wasn’t expressing himself properly; cc. He denied introducing Ms Richards to heroin, or at any stage purchasing or giving Ms Richards heroin. He denied ever injecting Ms Richards with speed or any other drug. He was not aware that Ms Richards was averse to using needles. He stated that he never saw Ms Richards using a needle and that he had never given her a needle; dd. He conceded to buying the needle sharps kit from the Sandgate Pharmacy on the day of Ms Richards’ death. However, he could not offer an explanation as to why he lied to the police when he advised him that he hadn’t; ee. He conceded that he told the police that he passed out for about half an hour at the most. He stated that it may have felt like half an hour to him at the time but it was obviously a lot longer; ff. He denied trading prescription drugs with anyone, including Ms Richards; gg. He knew that Ms Richards had smoked marijuana and that she was on a small variety of prescription drugs; hh. He denied taking drugs when he got to Ms Richards’ house. He stated that when he last saw the needle sharps kit, it was in his car.

He had not noticed any syringes in her apartment; ii. When confronted with the information he provided to the police that Ms Richards was his girlfriend and that they had just fallen in love, Findings of the inquest into the death of Karen Richards 28

he stated: ‘possibly over those last few days they’d gotten pretty close’. ‘It had grown’. It was not something that he ‘openly talked about’. But he wouldn’t ‘just jump into bed straight away with a person’; jj. He could not remember what the text messages from Ms Richards referencing bikies on the day of her death was about. He stated that he might not have even checked those messages, even though he had actually responded to them. He said he couldn’t relate to the subject matter. It seemed ‘really far-fetched’ to him. He denied dealing in drugs with bikies or having any involvement with them. He stated that Ms Richards did not have any involvement with bikies to his knowledge. He conceded that the text messages sounded like ‘pretty heavy involvement’ and that he had not responded with a query of any type asking what Ms Richards was talking about. He stated that was the type of response he would give; kk. He was not aware that Ms Richards had his phone number saved in her phone as ‘Demon Possessed’. He denied ever referring to her as a ‘piglet’; ll. He initially stated that he didn’t think that he had provided drugs to Ms Richards or Mr Alderwick a couple of days before her death. He later stated that he had never met Mr Alderwick and he did not provide the drugs; mm. He stated that the unlabeled Xanax medication in his car may have just been the inside of a packet and that he may have split the packet in half to leave some at home and leave some in the car; and nn. He stated that he had only noticed ‘puncture marks’ (not ‘track marks’) on Ms Richards’ arms whilst the Ambulance was there.

127. I found that Mr D’Amario was a dishonest witness. He continually changed his version of events in relation to material facts and he was evasive. I cannot rely on his evidence. He continually denied the obvious and only conceded to facts when presented with records of conversations with the 000 operator, ambulance crew and police.

128. The whole purpose of Mr D’Amario’s responses was to distance himself from Ms Richards and her death.

129. It has been proven to my satisfaction that Mr D’Amario has a history of drug dealing and drug supply which cannot be refuted.

Conclusions

130. Mr D’Amario was afforded an opportunity to respond to Counsel Assisting’s submissions but chose not to do so. I accept and adopt Mr De Waard’s submissions.

Findings of the inquest into the death of Karen Richards 29

131. After considering the totality of the evidence and the unreliability of Mr D’Amario’s evidence, I have drawn the following conclusions: a. Mr D’Amario and Ms Richards were in a sexual relationship at the time of her death. They had been together for around 12 months.

Their relationship centred around drugs; b. Mr D’Amario purchased the needle sharps kit found in Ms Richards’ room at the time of her death from the Sandgate Pharmacy between around 1:35pm and 2:00pm on 11 January 2014; c. Mr D’Amario arrived at Ms Richards’ house between 2:00pm and 3:00pm on 11 January 2014; d. Ms Richards was most likely affected by alcohol and prescription medication at the time of Mr D’Amario’s arrival; e. Mr D’Amario most likely supplied the heroin, which contributed to Ms Richards’ death; f. Mr D’Amario was well aware of Ms Richards’ heroin and drug use in general; g. Ms Richards took heroin on 11 January 2014, most likely some time in the afternoon or evening; h. It is possible that Ms Richards took the heroin with Mr D’Amario, or in his company. It is also possible that he injected her because she was averse to needles. However, this cannot be ascertained with any certainty (as it is noted that Mr Alderwick had witnessed Ms Richards inject herself with heroin once in the past); i. Mr D’Amario shared a bed with Ms Richards on 11 January 2014 but it cannot be ascertained whether they had sexual intercourse; j. Mr D’Amario most likely discovered that Ms Richards was unconscious between around 10:10pm and 10:40pm on 11 January 2014; k. Mr D’Amario did not phone 000 until 11:44pm. Therefore, he waited for between 1 hour 4 minutes and 1 hour 34 minutes before phoning emergency services; l. Mr D’Amario was calm and lacking in urgency because by the time he phoned 000, he had waited so long and it would have been obvious to him that Ms Richards was most likely already dead; m. Mr D’Amario referred to Ms Richards as a ‘cunt’ and ‘bitch’ when on the phone to the 000 operator; n. The delay, and demeaning way in which Mr D’Amario referred to Ms Richards on the phone with the 000 operator is likely to have been Findings of the inquest into the death of Karen Richards 30

caused by Mr D’Amario panicking and the low regard in which he held Ms Richards. He would have been worried that Ms Richards’ death could subject him to a police investigation and that he could come under scrutiny in relation to his supply of drugs and his own drug usage; and o. Mr D’Amario did not administer CPR or take any other life saving measures until instructed to do so by the 000 operator. He had to be continually prompted to keep doing so by the 000 operator.

Recommendation

132. Mr D’Amario’s failure to phone 000, to administer CPR, or to take life saving action within a reasonable time after Ms Richards lost consciousness was deplorable, to say the least. This is especially so, given that he was the only person present and able to save her life.

133. Under the Criminal Code Act 1999 (Qld), there is no relevant offence to cover such circumstances. The criminal law is only enlivened where the existence of a criminal duty of care can be established.

134. In the Northern Territory, there appears to be an offence to cover such circumstances under the Criminal Code Act (NT): Division 2 Provision of rescue, medical treatment and other aid 155 Failure to rescue, provide help, etc.

Any person who, being able to provide rescue, resuscitation, medical treatment, first aid or succour of any kind to a person urgently in need of it and whose life may be endangered if it is not provided, callously fails to do so is guilty of an offence and is liable to imprisonment for 7 years.

135. I recommend that the Queensland government adopt a similar provision to s. 155 of the Criminal Code Act (NT) in the Criminal Code Act 1999 (Qld). This may provide more incentive to people not to simply stand by when someone is dying, especially drug users in the context of drug overdoses.

136. I offer my condolences to the family and friends of Ms Richards.

137. I close the inquest.

John Hutton Coroner Brisbane 26 July 2017 Findings of the inquest into the death of Karen Richards 31