It was clear to Dr Riad that her patient would accept treatment, however he did not want to go to hospital. To accommodate another preference, Dr Riad arranged for him to be seen by an Arab-speaking P

It was clear to Dr Riad that her patient would accept treatment, however he did not want to go to hospital. To accommodate another preference, Dr Riad arranged for him to be seen by an Arab-speaking Psychiatrist.

Dr Riad believed her patient would be seen quickly by the Psychiatrist and did not believe his condition (at that time) required him to be scheduled under the Mental Health Act. He was a voluntary patient and had very good support from his family.

She had not been told of any expressed thoughts of suicide, so believed he was not at risk of self-harm nor a risk to others. Given his presentation, I agree with her assessment.
Dr Riad arranged with Awale to return in one week or earlier if necessary.
Unfortunately Dr Younan could not accommodate an appointment until February. Dr Riad was initially unaware of this complication.
When told that Dr Younan was unavailable, Sugule and Belinda sought to make other arrangements. Ms Moylan contacted a friend, Ms Rubina Khan, a clinical psychologist at Westmead Children’s Hospital. When told of Awale’s condition, Ms Khan very sensibly told the family to seek out a psychiatrist and gave them the phone number for the St George Acute Mental Health Team. That same afternoon, Ms Moylan rang the number and spoke to Nurse Evan Freeman. Nurse Freeman suggested an appointment the following day.
On Tuesday morning, 13 January, Nurse Freeman contacted Ms Moylan and a 2pm appointment was organised. Whilst Belinda and Segule attended for the assessment with Awale, Ms Moylan left the actual meeting to the men and Nurse Freeman.
Nurse Freeman assessed Awale Mohamed as ‘low risk’ and a ‘Management Plan’ was devised which included Awale attending psychiatrist Dr Younan.
Nurse Freeman presented the history of his patient at a Cross Over Team meeting that afternoon. The Psychiatric Registrar was part of that meeting.
That same day, Guled had taken his son to Dr Riad. During that consultation, Guled told the doctor that Awale had not been taking his medication and that the psychiatrist was unable to see him urgently. Later Dr Riad attempted to contact the Psychiatrist herself to no avail. She rang Guled to impress on him the real need to take Mr Mohamed to hospital.
Awale left the Hospital. The following day he had lunch with members of his family at Riverwood. After lunch he went to the shopping centre to buy cigarettes. It is there that he engaged in that fatal encounter with Mr Fitzhenry.

The Issues for Inquest

Mr Mohamed died during the course of a police operation and for that reason an inquest into the cause and manner of his death is mandatory under Section 13A, Coroners Act:

The issues for both the Coroner and Mr Mohamed’s family were the same:

• 
  Was the force used by Acting Inspector Ajaka justified in these circumstances?
  
• 
  Was Awale Mohamed shot in the execution of the police officer’s duty?
  
• 
  Did Awale Mohamed receive appropriate medical treatment on presentation to St George Hospital?
  

The Adequacy of the Medical Intervention

Nurse Freeman denies Belinda Moylan expressed her desire to have Awale assessed by a Psychiatrist. Ms Moylan’s evidence is very clear that the family wanted their cousin seen by a psychiatrist.

The evidence weighs in favour of Ms Moylan’s recollection and I find that the request for a doctor was in fact made to Nurse Freeman.
There is no doubt that the family was acting responsibly and urgently to get Awale assessed and treated. Dr Riad advised them of the need for a psychiatrist and they accepted that advice, trying themselves to arrange an appointment with Dr Younan. Belinda Moylan’s friend, Rubina Khan, an experienced clinical psychologist, advised Ms Moylan that Awale needed to be seen by a psychiatrist and furnished Belinda with the phone number of the mental health workers. They made immediate contact to arrange an urgent consultation. It is inconceivable that Ms Moylan would omit the one thing the family was chasing; that is an assessment by a specialist doctor.
Even Nurse Freeman’s evidence weighs in favour of Ms Moylan’s account. He tried to arrange the Psychiatric Registrar to review Mr Mohamed at 3pm however the doctor was not available at that time.
The New South Wales Department of Health reviewed the circumstances of Mr Mohamed’s treatment following his death. Professor David Greenburg, Forensic Psychiatrist, chaired the Review Panel. Its brief was to consider the possibility of any systemic failure of St George Hospital. The Mohamed family did not participate in the review and I can appreciate why they did not want to involve themselves at that stage.
The Review was extremely thorough and produced an honest Report into the circumstances of Mr Mohamed’s presentation and treatment at Hospital.
Nurse Freeman assessed Awale Mohamed using a ‘risk assessment rating scale’. The Reviewing Panel was critical of that process commenting that his ‘scale’ had not been validated. The scale was inadequate in rating risks of harm to himself or others and was non-specific in how to rate patients with multiple risk factors.
Nurse Freeman was Mr Mohamed’s ‘Primary Clinician’ and it was incumbent on him to undertake a comprehensive assessment of his patient. This would ensure appropriate ‘follow on’ treatment for Awale Mohamed.
St George Hospital had in place a ‘Primary Clinician Model and Role’ Policy to ensure the initial assessment of any patient was sound. This policy was devised to enable the initial clinician to determine if the patient needed to be immediately assessed by a psychiatrist.

Should it be determined that a psychiatrist is not required at that initial stage, the case history of the newly assessed patient is presented at the Cross Over Meeting. This is the course Mr Mohamed’s case management took.

The Reviewing Panel was critical that the process at these meetings did not allow sufficient discussion by all team members. Overload appears to be a factor with 8 new referrals per day added to an existing caseload of 32 to 38.
The Review found there were no policies to set out when a doctor should be involved in the assessment of a patient.
The Panel noted there were elements in Awale Mohamed’s presentation that necessitated assessment by a Psychiatrist;

• 
  First presentation at a mental health service
  
• 
  First episode of paranoid psychosis
  
• 
  Acute deterioration over three days preceding the assessment
  
• 
  Acting on his paranoid beliefs
  
• 
  Expressed thoughts of suicide
  

A Psychiatrist should have assessed Awale Mohamed on that Tuesday following his initial assessment by the Primary Clinician, Nurse Freeman.

Nurse Freeman’s judgement was way out of step with others trained and untrained that knew of Awale Mohamed’s mental disposition. Dr Riad’s initial assessment was;
That he needed urgent psychiatric intervention and tried to accommodate Awale’s phobia of attending hospital by organising a private clinician. Later when she discovered he was no longer compliant with her treatment, she urged the family to get him to hospital.
Ms Khan on hearing of his symptoms encouraged her friend to get Awale immediately assessed by a psychiatrist. Belinda Moylan, her husband and family wanted him assessed by a psychiatrist.
Mental Illness is not an exact science. Nurse Freeman knew of Awale’s earlier expressions of suicide. Too much reliance was given to the subjective features of his presentation and by that I mean, Awale stating that he was no longer suicidal. Dr Riad correctly diagnosed his deteriorating condition and understood the urgency in having him treated.

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