Pascoe, Rodney Dick

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Rodney Dick Pascoe TITLE OF COURT: Coroners Court JURISDICTION: Brisbane FILE NO(s): 2018/860 DELIVERED ON: 5 December 2019 DELIVERED AT: Brisbane HEARING DATE(s): 5 December 2019 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: CORONERS: Death in custody, Indigenous prisoner, natural causes.

REPRESENTATION: Counsel Assisting: Ms Rhiannon Helsen Queensland Corrective Services: Ms Nikola Core Cairns HHS: Ms Helen Price

Contents

Introduction

1. Mr Rodney Dick Pascoe was a 53 year old Aboriginal man, who died on 22 February 2018 at the Mareeba Hospital after being transferred from the Lotus Glen Correctional Centre on 14 February 2018, where he was a remand prisoner.

2. Mr Pascoe had a significant history of imprisonment, having been incarcerated on 52 occasions prior to his death.

The investigation

3. Detective Sergeant Stephen Carr from the Queensland Police Service (QPS) Corrective Services Investigation Unit (CSIU) led the investigation into the circumstances leading to Mr Pascoe’s death. He provided a brief report in March 2019.

4. The Corrective Services Investigation Unit (CSIU) was asked to carry out a targeted investigation to obtain relevant medical records, statements from medical officers involved in his care and identify any concerns from Mr Pascoe’s family. I was provided with a very helpful statement from Dr Margaret Purcell from the Mareeba Hospital who was a visiting medical officer at LGCC.

5. Detective Sergeant Carr’s Report concluded “The primary focus of a death in custody investigation of this nature to ensure ‘adequate medical care’ was given to the prisoner and that there are no suspicious circumstances surrounding the death. As the Investigating Officer, I am satisfied that it appears that adequate care has been provided in this case and there appears to be no suspicious circumstances in relation to this death.”

6. At the request of the Coroners Court, Dr Ian Home from the Clinical Forensic Medicine Unit (CFMU) also examined Mr Pascoe’s medical records from LGCC and relevant local hospitals and reported on them.

The inquest

7. As Mr Harrison died while in custody an inquest was required by s 27 of the Coroners Act 2003. Ms Helsen appeared as counsel assisting. All of the statements, records of interview, medical records, photographs and materials gathered during the investigations were tendered at the inquest.

Findings of the inquest into the death of Rodney Dick Pascoe

The evidence Personal history

8. Investigating officers obtained a statement from Mr Pascoe’s cousin, Jean Temple. Ms Temple told police that Mr Pascoe was known as ‘Coey’. She said that Mr Pascoe had three sisters and a brother who lived in Lockhart River. It appears that he led a largely itinerant lifestyle.

9. Ms Temple said that Mr Pascoe had problems with alcohol use for his entire life. She said that around the time of his death she had been told by medical staff at the Mareeba Hospital that Mr Pascoe had suffered liver damage due to his long-term alcohol use. No concerns were identified by Ms Temple about the care Mr Pascoe had received in prison or at the hospital.

Correctional and medical history

10. In the 12 months prior to his death, Mr Pascoe was incarcerated twice. During a period of remand at LGCC commencing in July 2017, he was deemed to be palliative for end of stage liver disease following an admission to the Cairns Hospital on 24 October 2017.1 There was some suspicion, following an abdominal CT scan at this time that he may also have hepatocellular carcinoma, although this was not confirmed.

11. Medical records indicate that Mr Pascoe received regular medical treatment and follow up while at LGCC through the Mareeba Hospital. His conditions were noted as being:2

• Alcoholic liver disease (diagnosed in October 2017 with evidence of advanced cirrhosis);

• Hepatic encephalopathy;

• Ischaemic heart disease (Mr Pascoe underwent coronary artery bypass grafting in 2011);

• Hypertension;

• Non-insulin dependent diabetes mellitus;

• Recurrent urinary tract infections; and

• Smoker.

Ex B1, [6] F iEnxd iBng1s, [o1f2 t]h e inquest into the death of Rodney Dick Pascoe

12. Records indicate that Mr Pascoe had regular and appropriate medical followup during this period of remand, which included nursing and specialist care, hospital admissions when necessary, engagement of a full time carer at LGCC, various medical treatments and extensive testing.3

13. After being released from LGCC on 20 November 2017, Mr Pascoe was admitted to the Mareeba Hospital for nursing care. His function had declined gradually, to the point where he required full-time nursing care. During this time, Mr Pascoe suffered from periods of incapacity. As such, steps were taken to arrange the appointment of the Adult Guardian, which took effect on 7 December 2017.4 After his functional capacity improved, he subsequently made the decision to return to Cairns, which was facilitated with bus transport organised.5

14. On 5 January 2018, Mr Pascoe was once again remanded at LGCC for sentencing in relation to a number of offences, namely three counts of Serious Assault, one count of Common Assault and one count of Public Nuisance. He was scheduled to be sentenced in the Cairns Magistrates Court on 9 March 2018.

15. On 8 January 2018, Mr Pascoe was examined by Blue Care nurses at the watchhouse during which his blood sugar levels were found to be high. He was transported to the Cairns Hospital for treatment of suspected hyperglycaemia with readings of 15.5. However, he was deemed fit for custody. There was no medication prescribed or administrated on this occasion, with his condition being monitored by watchhouse staff until he was collected by Correctional Officers from LGCC on 9 January 2018.6 A full-time carer was arranged.7

16. On 17 January 2018, Mr Pascoe exhibited fluctuating levels of consciousness after refusing his medication and was admitted to the Mareeba Hospital. His alertness slowly improved following treatment and he was returned to LGCC on 22 January 2018. A further similar incident occurred on 4 February 2018, for which he required an overnight admission.

17. On 14 February 2018, Mr Pascoe began to exhibit signs of altered consciousness. He was transported to the Mareeba Hospital where he was subsequently admitted. His principal diagnosis was Hepatic Encephalopathy and end stage liver failure. He was unable to stand or take anything orally. His care needs were reportedly beyond that which could be provided to him at

LGCC.

18. Mr Pascoe continued to receive full time nursing care at the Mareeba hospital, with his condition fluctuating each day. There was no treatment identified which could improve his condition.8 Ex B1, [19] – [37] Ex B1, [41] Ex B1, [43] Ex B1, [44] Ex B1, [44] F iEnxd iBng1s, [o5f1 t]h e– i[n5q3u]e st into the death of Rodney Dick Pascoe

19. On 18 February 2018, Mr Pascoe was transported to Cairns for further testing and it was established through a CT scan that ‘due to [Mr Pascoe’s] fluctuating conscious state and a large swelling found on his head, [Mr Pascoe] has severe hepatic encephalopathy. He could not sit, he could not stand, he had reduced power, he could not communicate, he was not orientated in time, place or person’. He was then returned to the Mareeba Hospital.

20. On 20 February 2018, following discussions with the Adult Guardian, a decision was made to cease all interventions provided to Mr Pascoe.

21. On 21 February 2018, medical staff at the Mareeba Hospital made a number of enquiries to see if Mr Pascoe could be granted parole or bail as his death seemed imminent.9

22. On 22 February 2018, Mr Pascoe was in the East Ward at the Mareeba Hospital under the guard of Corrections Officer, Mr Richard Knapp. At approximately 12:56am, Mr Knapp observed that Mr Pascoe appeared to have stopped breathing. He called hospital staff, who attended and declared life extinct at 1:40am.10 Autopsy

23. On 23 February 2018, an autopsy was conducted by pathologist, Dr Maxwell Stewart at the Cairns Hospital.11

24. Evidence of pleural adhesions, cirrhosis, chronic pancreatitis and bilateral pneumonia were found. Toxicology showed the presence of total morphine measuring 0.38 mg/kg, which falls just within the toxic range.

25. The cause of death was found to be pneumonia due to hepatic encephalopathy, which was due to cirrhosis. The other significant condition noted was chronic pancreatitis.

Medical Review

26. The Clinical Forensic Medicine Unit (CFMU) was asked to review the appropriateness of the medical care and treatment provided to Mr Pascoe by Offender Health Services, Cairns Hospital and Mareeba Hospital, particularly in the two months prior to his death. Forensic Medical Officer, Dr Ian Home subsequently provided an advice dated 8 August 2019.

27. Dr Home noted that Mr Pascoe died as a result of advanced alcoholic liver cirrhosis. His death was not unexpected. While hepatocellular carcinoma was not evident at autopsy, his condition was not amenable to treatment and led to Ex B1, [50] Ex A1 Fi nEdxin Ag3s of the inquest into the death of Rodney Dick Pascoe

recurrent episodes of impaired consciousness. The only definitive treatment would have been a liver transplant.

28. Dr Home identified no concerns about the quality of the care and treatment provided to Mr Pascoe by Offender Health Services, Cairns Hospital and the Mareeba Hospital, particularly during the two months prior to his death.

Conclusions

29. I am satisfied there is no evidence to indicate that Mr Pascoe died from anything other than natural causes. He received adequate and appropriate medical care while in the custody of Queensland Corrective Services, and at the Cairns and Mareeba Hospitals.

30. The circumstance of his death do not call for any comment relating to issues of public health and safety or the administration of justice or ways to prevent deaths from happening in similar circumstances.

31. Some hospital staff were reported to be distressed that Mr Pascoe died while he was cuffed to a bed, and considered that it would have been preferable for him to be released from custody or given bail to avoid dying in that manner.

Unfortunately, as a remand prisoner he was not eligible for parole and it appears a bail application was not lodged on his behalf.

Findings Required by s. 45

32. I am required to find, as far as is possible, the medical cause of death, who the deceased person was and when, where and how he came by his death. After considering all of the evidence I am able to make the following findings: Identity of the deceased – Rodney Dick Pascoe.

How he died - Mr Pascoe had a lengthy history of involvement with the correctional system, largely as a result of problematic alcohol use. He died at the Mareeba Hospital after he was transferred from the Lotus Glen Correctional Centre for palliative care for hepatic encephalopathy and end stage liver disease. He had been provided with regular medical care for these conditions during his incarceration on remand.

Place of death – Mareeba Hospital, Mareeba in the State of Queensland.

Date of death – 22 February 2018.

Findings of the inquest into the death of Rodney Dick Pascoe

Cause of death – Pneumonia, due to or as a consequence of hepatic encephalopathy, due to or as a consequence of cirrhosis. Chronic pancreatitis was a significant condition contributing to the death.

33. I close the inquest, and extend my condolences to Mr Pascoe’s family.

Terry Ryan State Coroner Brisbane 5 December 2019 Findings of the inquest into the death of Rodney Dick Pascoe