Report by the nsw state Coroner into deaths in custody/police operation
Dr Riad’s Treatment of Mr Mohamed
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- Nurse Freeman’s and Mr Mohamed
- Subsequent Changes
Dr Riad’s Treatment of Mr MohamedI agree with Mr Quinliven, Counsel for Dr Nadia Riad, that the doctor ‘anticipated that her patient would have received specialist psychiatric advice within that time’ (i.e. within the week). He urges that I find that Dr Riad’s overall treatment of her patient ‘exemplified a high order of thoughtfulness and diligence’. I agree. Nurse Freeman’s and Mr MohamedWhilst it was not part of this Coroners brief to delve into the overall resourcing of Mental Health Services at St George Hospital, it was evident in Nurse Freeman’s evidence that the system was stressed at the time of Mr Mohamed’s presentation. The mental health of a deceased is too often a factor to be considered at inquest. The Mental Health System is frequently under scrutiny for that reason. Coroners have, over a number of years, recommended much needed changes to the System to ensure the mentally ill, and the families that have to cope with the condition, are properly catered for. Nurse Freeman’s assessment process was flawed. He did however ensure that Mr Mohamed was seen by a Primary Clinician (himself) for assessment as soon as possible. He spent time with Mr Mohamed and his cousin and tried to engage the Psychiatric Registrar. Nurse Freeman phone the family the next day to follow up on Awale’s state of health. The next contact Nurse Freeman had with Mr Mohamed was to identify him to police in the Emergency Ward following the shooting. Given Awale Mohamed’s presentation during the assessment, and the personal history provided by the family at hospital and during the earlier phone conversation, he should not have been released from hospital without being seen by a psychiatrist. Mr Gregg Counsel for the South Eastern Sydney and Illawarra Area Health Service, in his submission states: “Any attempt to analyse and classify psychiatric disorders is necessarily subject to a variety of difficulties and obstacles. It is helpful to consider the observations of Dr Peter Shea in the second edition of his book ‘Psychiatry in Court’, Hawkins Press 1996. Dr Shea, a forensic psychiatrist, is a former president of the Mental Health Review Tribunal, an Associated Professor at Sydney University and occupies a senior position at Morisset Hospital: ‘Mental Health and Mental illness or mental disorder are impossible to define in general terms (a) because there are socially and culturally determined, and (b) because there are both subjective and objective elements involved. The result. Is that there is no single definition. That comes anywhere near to encompassing a general professional consensus’ Mr Gregg further submits “The diagnosis or determination of ‘mental illness’ whether for the purpose of the Mental Health Act 1990, or more generally, can thus be seen to depend upon the extent to which the subject is displaying the relevant symptoms in any particular point in time. “This is particularly important in this case since all any clinician can do is to examine the subject to determine what if any symptoms are present and thereafter use clinical judgement to determine the seriousness of such symptoms and to make a diagnosis”. There is no part of this submission that I disagree with. A ‘Clinical Judgement’ was the crucial factor with Awale Mohamed. The primary clinician, Nurse Freeman, placed great weight on his patient saying he was not suicidal and that did he did not have plans to ‘self-harm’. The objective features i.e. the reports from his family, his deteriorating mental condition over the preceding days and, added to that, the background of Mr Mohamed being a political refugee (in terms of his paranoia), should have factored considerably in his assessment. It was clear that Nurse Freeman was working within a framework that was accepted practice at the Hospital. Dr Bruce Westmore, Forensic Psychiatrist, agreed with the observations of the Reviewing Panel that there were sufficient indicators to suggest Mr Mohamed should have been seen by a psychiatrist and that such assessment should have been undertaken at presentation at the Acute Mental Health Unit. Dr Westmore opines the Nurse should have contacted the Psychiatric Registrar to have them attend Mr Mohamed. He believes that the assessment scale can be both useful and problematic and that ‘they were no substitute for a proper clinical assessment’. Dr Westmore took a broad approach to assessment and stated that a psychiatrist for expert assessment should see all presentations like Mr Mohamed. He likens the situation to that of a medical patient who presents at a hospital failing to be seen by a medical doctor. I agree. Professor Greenburg does not embrace that proposal, however he opined as a professional and experienced psychiatrist, that a psychiatrist should have seen Awale Mohamed on presentation. He qualified this as a ‘personal’ opinion based on his acquired knowledge. These opinions, as well as years of experience dealing with the same issues at inquest time after time, convince me that the only solution to this significant issue is to have all ‘first time’ presentations seen by a psychiatrist or psychiatric registrar for assessment. Subsequent ChangesI accept the submission by Mr Gregg, that implementing strict guidelines for minimum staffing requirements will always be problematic due to worldwide shortages of psychiatric practitioners. Mr David McGrath, Director of Mental Health and Drug and Alcohol Programs, submits that the problem requires a national action plan to produce a much greater number of undergraduate training places in medicine and nursing. It appears to be recognised that appropriate resourcing of mental health services is at a critical level. I also accept that the Area Health Service has responded appropriately in reviewing this critical incident. It is obvious from the evidence given at inquest that there has been a marked improvement in guidelines and protocols dealing with the assessment of the mentally ill. It is also noted that systems are continually evolving. Circular 060 ‘Responsibilities of Registrars and Consultants for the Acute Community Care Team has been developed to ensure the Registrar is available to discuss:
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