An inquest into the disappearance of a Sydney man last seen six years ago has heard conflicting opinions about his diagnosis and care in the days before his suspected death.
The 32-year-old, who cannot be identified for legal reasons, is believed to have taken his life at The Gap in Sydney’s east on April 4, 2017, hours after he was discharged from a mental health unit.
Days before his suspected death, on April 1, the 32-year-old — who had struggled with his mental health and had drug abuse issues — was arrested by police at the same spot.
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He was taken into custody before being transferred to Randwick’s Prince of Wales Hospital, where he was assessed and admitted to the Kiloh Centre — a mental health facility.
He stayed there over the next two days — without the knowledge of his family — as an involuntary patient before being discharged on April 4.
It’s believed he then took his life at the same spot he was arrested at days earlier. CCTV from The Gap that evening showed a male there that matched his description.
A police investigation and search commenced shortly after, but his body has never been found.
The inquest, which began last month in the NSW Coroner’s Court, came as a relief to his family, who have been waiting years for answers and a death certificate.
While the family had already accepted the 32-year-old was dead, in the six years they waited for an inquest, they were not able to properly farewell their son and brother.
“There’s a certain amount of relief that things are happening,” the man’s sister said outside court.
“It’s the waiting and not knowing that hurts.”
The inquest examined the care and treatment the Sydney man received during his admission at the Kiloh Centre, why his family weren’t contacted by the Kiloh Centre in that period, and whether it was appropriate for him to have been discharged from the facility on his own.
It heard from the lead detective in the missing persons investigation, health staff involved in the man’s care in the days and months before his suspected death and independent experts.
The adequacy of mental health procedures in the lead-up to the man’s suspected death were also scrutinised.
Inquest begins
Magistrate Joan Baptie opened the inquest on July 25 by sending the court’s condolences to the man’s family.
“I’m sorry that we gather in these circumstances,” she said, addressing family members sitting at the back of the courtroom.
In her opening statement, counsel assisting Amanda Chytra told the inquest “on the balance of probabilities (the 32-year-old) has died”.
Detective Sergeant Michael Egan, who was the lead detective on the case when the 32-year-old was reported missing, said he believed the man had died at The Gap hours after leaving the Kiloh Centre.
The inquest heard that since April 4, 2017, there has been no record of the 32-year-old having accessed any of his bank accounts or government welfare.
In the weeks leading up to his admission, the inquest heard the man had experienced several episodes of psychosis.
His treating psychiatrist Dr Usman Malik, who had treated him for about two years at private mental health facility the Hills Clinic, said he had been diagnosed with a schizoaffective disorder, a condition which the doctor considered a major mental illness.
Upon being admitted to the Kiloh Centre, the man was reported to be delusional and exhibiting suicidal ideation. He also appeared anti-social and agitated.
However, the inquest heard there were differing opinions on the man’s diagnosis at his admission.
When he presented at the Kiloh Centre, he was diagnosed with a drug-induced psychosis, based on the fact that he tested positive for amphetamines and had presented with psychotic symptoms, the psychiatry registrar at the time, Doctor Pui Hon Koh told the inquest.
Professor Philip Mitchell, who was the consultant psychiatrist with the team at the time of the man’s presentation, agreed with the diagnosis, based on the assumption the man had taken methamphetamine.
The inquest heard the man had told doctors he took methamphetamine days before his admission on April 1, but Professor Mitchell said he questioned that timeline.
Independent expert, forensic psychiatrist Dr Andrew Ellis, told the inquest he believed the diagnosis was one of an “underlying mental illness exacerbated by the drug use”. A second independent expert, forensic psychiatrist Doctor Gerald Chew, agreed.
But a third expert, Associate Professor Christopher Ryan, said he was of the opinion the man was experiencing a drug-induced psychosis and said it was “reasonable” doctors at the Kiloh Centre came to that conclusion based on the information they had.
Obtaining collateral data
During the man’s admission, Dr Koh told the inquest he made efforts to obtain collateral information via fax from the Hills Clinic. While that information was never received, he said he believed he had enough information when making the decision to discharge the patient.
When asked why he didn’t follow up in obtaining that information when he didn’t receive a response, Dr Koh said: “Because I don’t even remember whether I had sent a request or not, and it was likely as a result of my workload at the time.”
He also told the inquest, in hindsight, and having seen that collateral information since, he would not change his decision to discharge the patient but agreed the use of a fax machine was problematic.
Professor Mitchell told the inquest he was also aware a request for information had been made and agreed he too wouldn’t have changed his mind in discharging the 32-year-old, even after seeing the information from the Hills Clinic and the evidence from Dr Malik.
“I don’t think there was any grounds to continue any involuntary treatment,” he said of his assessment of the man shortly before he was discharged.
When asked if in hindsight he thought it might have been appropriate to contact Dr Malik to discuss the man’s presentation, he said: “looking back I don’t think there was a necessary, stong need to speak to Dr Malik. It wasn’t critical in decision-making.”
Professor Mitchell said he was aware of the diagnosis of a schizoaffective disorder but said on observation on the ward, “there was nothing to suggest ongoing psychotic illness”.
In addition to the failed attempt to obtain information from the Hills Clinic, the inquest also heard during the man’s admission, there was no contact between the Kiloh Centre and his treating psychiatrist Dr Malik.
Dr Malik told the inquest he had not been made aware a request for information had been sent from the Kiloh Centre, and that he first became aware the man had been admitted to the Kiloh Centre was when he was contacted as part of the police investigation into the man’s disappearance.
He said if he had been contacted by the Kiloh Centre, he would have expressed concern upon hearing the man had been exhibiting antisocial behaviour.
“I would’ve discussed the fact that he’s never been antisocial before … that new behaviour — the antisocial behaviour — would be a sign of mental illness,” he told the inquest.
He said drugs could have contributed to his psychosis and exacerbated it.
When asked about his opinion on the man’s state of mind at the time of his suspected suicide, Dr Malik said: “He would have been mentally ill enough to make the decision to (take his life).”
If he hadn’t been mentally ill, he “would not have (taken his life) at The Gap,” Dr Malik said.
Dr Ellis told the inquest the decision to discharge the patient was “not unreasonable” with the information the team had at the time.
“I think the decision to discharge the patient does not come from diagnosis. I would think that hearing all the evidence, having the benefit in hindsight … that it may not have led to a decision to further detain him in order to continue his treatment … but I think it raises some questions about the form in which you discharge someone in the involvement of family and the involvement of support services,” he said.
When asked if he thought it was reasonable to not follow up with the Hills Clinic for the collateral information, Dr Ellis said: “overall, if it’s time-consuming and futile to extract the information, you’re going to have to make a decision, you can’t detain people over ‘what-ifs’.
“There may not have been enough time to get in contact, then it would be unreasonable to seek that information. It’s difficult to say how much time the staff had to find that information,” he said.
However, he said: “I don’t think it was unreasonable to make a phone call to the clinic or to Dr Malik.”
Dr Ellis also questioned the use of fax machines by hospitals.
“I think NSW Health really needs to look hard at the use of fax machines. They are a notoriously unreliable,” he said.
Before his discharge, doctors began a mental health assessment on the patient, but were unable to finish it. They planned to complete it in two days if he was still in hospital, but he was discharged later that day, the inquest heard.
Dr Ryan also told the inquest if it were the case that the team were to have understood that information hadn’t come back yet “it would be reasonable to let him leave rather than wait for the information”.
“It would have been hard to continue to detain him given his history and his wish to be discharged,” he said.
Family contact
The inquest heard at no point were the man’s family advised of his whereabouts when he was admitted, or told their son and brother was experiencing a psychotic episode.
The man did not nominate a next of kin, the inquest heard, and it’s not been established whether he consented to family being contacted.
Dr Koh told the inquest he couldn’t recall whether or not staff had specifically asked him whether or not he consented to have his next of kin contacted.
“Documentation in this instance was not as detailed as it could’ve been,” Dr Koh said.
However, he said, based on his clinical notes, it was reasonable to assume there was some sort of refusal to provide next of kin details.
In his evidence, Dr Malik told the inquest the man had never expressed that he didn’t want his family contacted and said his father had been his nominated support person at the Hills Clinic.
Associate Professor Ryan said he would have anticipated the treating team would have spoken to the man’s father.
“It would normally be the case that if someone would refuse their family member be contacted, to ask why that was and that would open the conversation if there was someone else to contact,” he said.
Dr Ellis also said the involvement of the family at the decision to discharge would have been a good decision.
“It’s always good clinical practice to involve family members where it’s at all possible where it’s someone with illness in hospital,” he said.
Questions were also raised about the drugs prescribed to the man — including anti-psychotic drug lisdexamfetamine — which can appear in blood tests as an amphetamine.
At the conclusion of giving his evidence before the inquest, Dr Koh addressed the man’s family directly.
“I haven’t had a chance to speak to you or meet you in person to offer my apologies for what’s happened,” he said.
“It’s quite a shock, and as a psychotherapist at the moment, I’m still processing that and strive to learn from this both internally and with patient care.
“I felt quite emotional today seeing you.”
Family’s pain
While the inquest has come as relief to the family, they’re still waiting to receive a death certificate for their son and brother to finally be able to farewell him.
“This isn’t about blaming anyone for his death, it’s about finding out what happened in those last two days,” his sister said.
“My brother walked in and lit up a room.
“He could talk to anyone. He was full of life and full of laughter. He had this laugh … it was very loud, and it was a big belly laugh.”
They’re also calling on the health system to undergo a reform to better understand how to deal with mental health and drug issues.
At the end of the inquest, Magistrate Baptie will determine whether the man is deceased, his manner and cause of death.
The inquest will is set to continue for one day in September.
If you need help in a crisis, call Lifeline on 13 11 14. For further information about depression contact beyondblue on 1300224636 or talk to your GP, local health professional or someone you trust.