Deceased
OA
Demographics
44y, male
Coroner
Decision ofDeputy State Coroner Kennedy
Date of death
2020-02-12
Finding date
2024-03-13
Cause of death
multiple injuries from fall from cliff
AI-generated summary
A 44-year-old man with familial Mediterranean fever (FMF) and bipolar affective disorder with drug-induced psychosis died following a fall from a cliff at Vaucluse during a police rescue operation. He had been managing severe FMF pain with oxycodone, which he subsequently prescription-shopped from multiple doctors. Following detection of doctor shopping in March 2019, his access to Endone was restricted. He began self-medicating with cocaine in mid-2019, leading to admission with drug-induced psychosis in November 2019. After discharge, despite mental health support and anti-psychotic medication, his mental state deteriorated with increased paranoia, substance use, and suicidal ideation. On the night of death, police rescue officers engaged with him for over an hour on a cliff edge in poor weather; during a rescue attempt, he slipped from the officer's grip and fell. The coroner found the police response adequate and appropriate, hospital care adequate, and medical management of his pain reasonable given limited treatment options at the time. The death was determined to be misadventure rather than intentional.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of OA (a pseudonym) Hearing dates: 11-13 March 2024 Date of findings: 13 March 2024 Place of findings: Coroner’s Court of New South Wales, Lidcombe Findings of: Deputy State Coroner, Magistrate Erin Kennedy Catchwords: CORONIAL LAW – death as a result of fall from height – police operation – whether police response was adequate and appropriate – whether care and treatment provided by hospital was adequate and appropriate – whether medical conditions and associated pain was adequately managed – whether death was self-inflicted File number: 2020/00048323 Representation: Counsel Assisting: Dr C Palmer, instructed by Ms C Potocki (Crown Solicitor’s Office) Family (CA): S Woodland, instructed by J Green (Gibson Howlin Lawyers) New South Wales Commissioner of Police and Sergeant L Barrett: R Hood, instructed by S Robinson (the Office of General Counsel NSWPF) South Eastern Sydney Local Health District: K Kumar, instructed by A Pascoli (Makinson d’Apice)
Findings: Identity The person who died was OA.
Date of death OA died at 11.42 pm on 20 February 2020.
Place of death The location of OA’s death was lighthouse reserve, Christison Park, Vaucluse, NSW 2030.
Cause of death OA died as a result of multiple injuries.
Manner of death OA’s death was the result of misadventure (fall from height after taking himself to a cliff edge and during the course of police attempts to save him).
Recommendations Nil.
Non-publication orders Non-publication orders made on 11 March 2024 and 12 March 2024 prohibit the publication of various persons personal information and particular evidence in the brief of evidence. The orders can be obtained on application to the Coroners Court registry.
Pursuant to section 75 of the Coroners Act 2009 (NSW) I direct that there be no publication of any matter (including the publication of any photograph or other pictorial representation) that identifies:
(a) the deceased person (anonymised as “OA”);
(b) the deceased person’s relatives as that term is defined in s. 75(3)); and/or
(c) a parent or sibling of the spouse of the deceased person.
Contents Whether an inquest into OA’s death is mandatory on the basis that it was “as a result of police Whether OA’s FMF, associated pain and other medical conditions were adequately managed and
Whether the care and treatment received by OA at St George Hospital between 1 November Whether the response of the NSW Police Force response to OA’s attendance at The Gap on 12
Background to Inquest
OA was 44 when he died at approximately 11.42pm on 12 February 2020 after falling from a cliff near Old South Head Road, Vaucluse. Officers from the NSW Police Force (“NSWPF”) were in attendance at the time and had attempted to engage with OA of over one hour prior to his fall.
OA also suffered from a rare genetic condition known as Familial Mediterranean Fever (“FMF”), which is a debilitating condition characterised by recurrent episodes of painful inflammation in the abdomen, chest, or joints. OA experienced significant pain due to this condition and was prescribed a variety of medications to address this pain, including Endone (oxycodone). It appears that in the months preceding his death, OA’s mental state severely deteriorated. He was diagnosed with bi-polar disorder. He became increasingly paranoid and agitated and believed that his wife was keeping important personal matters from him. He presented to hospital months prior to his death in November 2019 with drug induced psychosis and was scheduled as a result.
In the months leading to his death his level of paranoia increased dramatically.
On the evening of his death, OA picked up his wife in his car and asked her to go for a drive to talk. Just before 10:15pm, OA parked the car near Macquarie Lighthouse on Old South Head Road, Vaucluse. He remarked to his wife that she did not want to be with him, left the car and walked towards the cliffs at the Lighthouse Reserve, which is the park surrounding the lighthouse. She called family and emergency services were notified.
At around 10.37pm, officers from the NSWPF Rescue Unit located OA, sitting over a fence on the cliff face. They commenced communicating with OA. At 11:42pm, OA fell from the cliff. His death was declared a critical incident in accordance with NSWPF guidelines.
Direct cause of death
Whether an inquest into OA’s death is mandatory on the basis that it was “as a result of police operations”
Pursuant to s. 27(1)(b) of the Act, an inquest into OA’s death is therefore mandatory.
This is not to suggest that OA’s death was in any way caused by the intervention of police, they engaged when he was on the rockface in an attempt to save him. As will be discussed below there were multiple causal factors that contributed to OA’s death.
Function under the Coroners Act
The primary function is provided by s. 81 of the Act. It is to make findings as to: a. the identity of the deceased; b. the date and place of the person’s death; and c. the manner and cause of the person’s death.
Pursuant to s. 82 of the Act, the Coroner may make recommendations in relation to any matter connected with the death. Recommendations relating to public health and safety are specifically mentioned in the Act as an example of the category of recommendations that might be appropriate.
The issues
Whether OA’s FMF, associated pain and other medical conditions were adequately managed and the impact on OA of his use of Endone (oxycodone).
Whether the care and treatment received by OA at St George Hospital between 1 November 2019 and 4 November 2019 was adequate and appropriate.
Whether the response of the NSW Police Force response to OA’s attendance at The Gap on 12 February 2020 was adequate and appropriate, including: i. the attempts undertaken by NSW Police Force officers to engage OA in discussion and negotiation once they had located him on the cliff face at 10:37pm; ii. the attempts undertaken by NSW Police Force officers to contact the NSW Police Force Negotiation Unit and procedures in place to ensure
that the Negotiation Unit can readily contact NSWPF officers present at the scene; and iii. whether any relevant NSWPF Standard Operating Procedures (“SOPS”) or policies were adhered to.
Whether OA’s death was intentionally self-inflicted.
Whether it is necessary or desirable to make any recommendations in relation to any matter connected to OA’s death pursuant to s. 82 of the Act.
Nature of the inquest
In effect the proceedings were to explore the manner and cause of OA’s death in light of the intervention of police in the matter pursuant to the Act.
Background to OA
An inquest is the inquiry into the death of an individual, making it important to reflect on the person who was the focus of that inquiry. OA was a son, brother, father, partner, and friend. He was much loved and admired. He was hard working, committed to his family and is much missed.
OA was born on 26 March 1976 and grew up in Hurstville, Sydney. OA had an older brother, a younger sister, and a younger brother. His eldest brother, GA, gave evidence in the inquest by way of statement, and participated in the inquest proceedings. He has given evidence that that the four children enjoyed a normal childhood and were raised in the tradition of the Islamic faith.
When he was around 13 or 14 years old, OA’s father passed away due to cancer. During OA’s admission for mental health treatment at St George Hospital in late 2019, his medical notes indicated that OA reflected that he had suffered significantly as a result of his father’s passing.
OA left school in Year 9 and worked in panel beating and spray-painting. He then moved to Lebanon for 12 months where he learned to be a barber. Upon his return to Sydney, OA undertook various jobs before starting his own business specialising in leasing out mechanical equipment.
Marriage and Family
OA met his wife in 1999. They were introduced by his older brother. According to his wife, they married in 2008. However, GA states that there was also an earlier private wedding in the traditions of the Islamic faith on 11 February 2006.
OA and CA had two children together. Up until October 2019, CA considered that she and OA had a normal relationship. She commented that they did everything together.
CA described OA as outgoing and the type of guy that “after you met him the first time you would love him.” For most of their relationship, CA said that she felt OA did not have any depression or anxiety. She did not know him to take drugs or drink alcohol.
BF, a colleague who worked with OA in his business, said that OA was a fun, energetic and happy man. He was the type of guy who would give anyone a chance as long as they were a good person and wanted to learn.
At one point, OA reportedly said that he had not spoken to his brother for 21 years because his family had disowned him for marrying a Christian woman. CA also stated that to her knowledge OA had not been in communication with his immediate family since around 2006.
However, according to his brother he was in regular contact with OA, and they spoke on every week or two. GA said that OA would not call him from his own phone, but from another number so that his wife could not see from phone records that he was in contact with his family.
OA’s colleague referred to above, BP, stated that OA told him he had lost contact with his family because he was Muslim and CA was Catholic, but OA would never force her to convert.
The Business
Physical health
OA had multiple physical complaints and a complex medical history including Familial Mediterranean Fever (or “FMF”) and hepatitis. FMF is an inherited autoinflammatory condition, characterised by recurrent attacks of fever, inflammation of the lining of the abdomen and lungs, painful, swollen joints, and an ankle rash. FMF may also cause issues in the kidneys and testicles. OA’s FMF was not diagnosed until late 2016 whish is later for the condition.
OA’s General Practitioner (“GP”) was Dr Rowan Vickers. OA first consulted Dr Vickers in 2006 for bronchitis and sinusitis. In a statement provided to the Court, Dr Vickers summarised his consultations with OA over the period of care. Dr Vickers noted diagnoses of FMF (with associated complications), hypertension, hypogonadism, migraines, and anxiety with possible manic depression. He noted early presentations of anxiety and stress and that OA had suffered migraines. He then documented a period during which OA had a number of physical ailments that lead up to the diagnosis of FMF.
In 2016, OA presented to Dr Vickers with “kidney involvement, abdominal involvement, inflammatory arthritis, oligoclonal band in blood and elevated inflammatory markers”.
Dr Vickers then referred OA to Professor George Mangos at the rheumatology clinic, who saw OA on 6 December 2016. On the same date, Professor Mangos wrote to
Dr Vickers and noted OA was clearly an unwell man, stating that OA used Voltaren every few days for headaches. Professor Mangos noted that OA presented with a systemic illness that caused significant weight loss, headaches, lower limb pain, leg swelling and a photosensitive rash over the upper limbs. OA also suffered from lethargy, nose bleeds, reflux, tooth pain, sinus pain, skin rash and “arthralgias/myalgias”. In early December 2016, OA did not yet have a diagnosis and his medical specialists were arranging further blood tests and possible biopsies. OA was eventually diagnosed with FMF in late 2016.
After his diagnosis, Dr Vickers referred OA to Dr Roncolato (haematologist) in September 2017. On 5 February 2018, and 12 March 2019, OA was referred to Professor Denis Wakefield, immunologist. On 14 March 2019, OA was referred to Dr Frederick Joshua, rheumatologist. On 3 April 2019, OA was referred to Dr Wassim Rahman, gastroenterologist. Other medical specialists were also involved in OA’s care.
In addition to FMF, OA was diagnosed with stage 1 chronic kidney disease in July 2017, and again saw Professor Mangos who prescribed him Lyrica (pregabalin) throughout 2016-2017. OA also had a bone lesion in his clavicle, for which he saw Dr Joshua in September 2017 and was having regular specialist reviews as of 23 October 2017.
OA also had low testosterone for which he saw Dr Peter Nash, at the Urology Practice, Miranda. He received testosterone injections from Dr Nash and was monitored by blood tests.
As is evident in the brief of evidence that was tendered in these proceedings, communications with the treating team were principally through comprehensive letters sent to Dr Vickers. Dr Vickers provided in his statement that: “it was extremely difficult to determine whether [OA’s] kidney disease, inflammatory arthritis, febrile illness, low testosterone, prostatitis, chronic headaches, anxiety and agitation together with his weight loss were all part of his Familial Mediterranean Fever or separate issues.”
Dr Vickers noted OA’s hypertension and weight, which were being monitored, and were possibly also related to his FMF. In late 2019 and early 2020, he observed that OA had deteriorated mentally but he still did not believe he was a risk to himself or to others. He had referred OA in late 2019/early 2020 to psychologist Mr Sam Borenstein and psychiatrist Dr David Hughes. Dr Vickers felt, however, that OA simply did not want to go to a mental health specialist.
Medications - Endone
It appears that in the years preceding his death, OA procured a variety of medication, including vast amounts of Endone (oxycodone) from a range of medical practitioners as well as his regular medical practitioners.
Dr Vickers noted that oxycodone 5mg (Endone) was commenced in about 2008 for management of pain due to a back injury. He was given oxycodone 5mg tablets to manage migraine headaches in 2009, 2012 and 2015. He was discharged from hospital on oxycodone in November 2015 and required further prescriptions during 2015, 2016
and 2017. The use of oxycodone to manage his pain was generally endorsed by specialists OA was consulting.
It appeared to coincide with his diagnosis, in 2016, that his difficult relationship with pain killers began in earnest. OA was prescribed oxycodone (Endone) on 20 occasions, by five different prescribers. Then after his diagnosis with FMF in late 2016 to early 2017, OA’s Endone use rapidly escalated. In 2017, OA was prescribed oxycodone (Endone) on 40 occasions by 14 different prescribers.
On 7 December 2017, it was noted OA was asking for Endone and had a “prior history of Endone overusage”. A prescription was declined, and he was given Panadeine Forte.
In 2018, OA was prescribed oxycodone (Endone) on 80 occasions by 19 different prescribers and attended some 24 different pharmacies for its supply.
One concerning example of OA being able to source an oversupply of Endone is the period from 24 January 2019 to 29 January 2019, where he visited six different prescribers in a five-day period, obtaining an Endone prescription each time.
In addition to his prescriptions, OA also attended St George Hospital on nine occasions between 2015 and 2019 and was given pain relief medications including paracetamol and oxycodone (Endone and OxyContin). On 10 December 2016, staff noted that OA requested “increasing amounts of prn Endone. Frequency currently hourly – each dose of Endone only lasting the hour.” The Pain Management Team reviewed OA during that same admission and noted he had been given “high dose opioids” and planned to wean him off OxyContin (oxycodone) but continue with Endone (oxycodone). It also appears that OA occasionally attended St George Hospital for the sole purpose of obtaining Endone, and that he did not feel the usual soporific effects of Endone (oxycodone).
When given Endone (oxycodone) on 18 November 2015, OA was advised that he could not work or drive while affected. However, on 18 August 2016, after presenting to the emergency department with diarrhoea, Dr Matthew Bode, registrar, noted the following: “Patient declined blds or IV fluids as he has to be at his workplace in 15 minutes. Declines further investigations. Adamant that he wants to leave after analgesia only. Unable to persuade otherwise.”
On or about 13 February 2017, OA discussed with Dr Vickers and another clinician at that clinic, Dr Allison Vickers, a plan to consider reducing the amount of oxycodone 5mg “which he seemed amenable”. A plan was developed on 20 February 2017. OA was prescribed amitriptyline 25mg daily for pain which was noted to be not “greatly effective.” Oxycodone prescriptions were ceased by the clinic.
On 6 September 2017, OA was given a prescription of oxycodone 5mg to manage severe pain. The prescriptions continued over the end of 2017 and beginning of 2018 with the support of Professor Frederick Joshua. The oxycodone dosing was noted to decrease in mid-2018. A plan to reduce his oxycodone use was developed on 2 November 2018 with a final plan to cease the oxycodone on 13 February 2019.
On 11 March 2019, Dr Rowan Vickers received a letter from the Prescription Shopping Program (“PSP”) indicating that OA had consulted 12 doctors who had prescribed 31 prescriptions of oxycodone 5mg in a three month period. The letter outlined that
OA had received 31 scripts from 12 doctors in the 3 months from 1 December 2018 to 28 February 2019. Dr Vickers gave evidence that only 9 of these scripts were from him, and that this was when OA had agreed to slowly decrease his dosing of oxycodone 5mg. Dr Vickers informed OA he was no longer comfortable prescribing the oxycodone.
Dr Vickers noted that in over 30 years of practice, this was the only letter he had received from the PSP. He assumed all doctors who had prescribed oxycodone to OA received the letter.
In relation to the pain experienced by OA, Dr Vickers gave evidence as follows. OA’s pain was brutal. This was particularly evident in 2015 when he presented with the painful swollen ankle, and in 2016 when he presented systemically unwell with abdominal pain. He presented on so many occasions in such distress unable to function with generalised aches and pains and severe abdominal pain presumed to be peritonitis. This was supported by elevated inflammatory markers. Oxycodone allowed him to continue to function and was prescribed on an understanding that successful alternative management was being explored by his specialist team. Unfortunately, he did not appear to respond to alternative treatments despite dedicated efforts by his specialist team including accessing medications on compassionate grounds in their efforts to help OA.
On 13 March 2019, Professor Denis Wakefield wrote to Dr Vickers, copying in Dr Joshua, regarding their treatment of OA’s FMF. Professor Wakefield noted that OA had been on Humira (adalimumab) 40mg subcutaneously every week and still woke each day with severe abdominal pain. Professor Wakefield also stated that OA had new symptoms of severe right shoulder pain and episodes of increasing sweating.
Professor Wakefield stated that they were planning to continue Humira (adalimumab) for a month before deciding whether it was ineffective, and that OA was also taking colchicine twice daily. In his letter, Professor Wakefield stated: “He is trying to limit his intake of Endone, unfortunately he is in chronic pain. As you know we receive correspondence with regards to him doctor shopping. He is keen to get off the Endone and I think this is really a sign of the fact that we are not adequately controlling his
Professor Wakefield stated that this dose was higher than what OA had previously told him he was taking. Professor Wakefield stated that he referred OA to the Pain Clinic at St George Hospital and gave OA one more prescription for Endone (oxycodone), although this prescription by Professor Wakefield does not appear in the Pharmaceutical Benefits Scheme Patient Summary (“PBS Summary”). There also does not appear to be records of OA visiting a pain clinic in March 2019. The PBS Summary records OA being prescribed oxycodone by Dr Divya Vaswani, GP in South Hurstville, on 15 March 2019. There were no further prescriptions written in the second half of March 2019.
On 21 March 2019, Professor Wakefield sent Dr Vickers correspondence indicating he had also received a letter from the PSP but continued to feel OA needed oxycodone for the pain. OA was referred to the pain management team. On 29 March 2019, Professor Wakefield in correspondence requested Dr Vickers prescribe a narcotic patch. On 10 April 2019, OA continued to experience severe pain and Dr Vickers prescribed Panadeine Forte. He received a maximum of 120 in a month (four tablets per day).
From the dispensing history on OA’s PBS Summary, the above communications between his treating team resulted in him having significantly less access to Endone.
From April 2019, no Endone prescriptions were written by OA’s treating team. In January and February 2019, OA had been dispensed with oxycodone (Endone) on 23 occasions. In March and April 2019, OA was dispensed with oxycodone (Endone) on 12 occasions, and also collected scripts for tramadol (an opioid analgesic), and paracetamol and codeine (Panadeine Forte).
On 31 May 2019, OA presented with epigastric pain and sought Endone, which was prescribed. It was noted “discussed drug addiction.” Dr Khan obtained PBS information from the PSIS noting that from 1 March 2019 to 31 May 2019, OA had 12 prescribers and prescriptions of oxycodone and 4 prescriptions of Panadeine Forte in addition to other medications. On 7 June 2019, OA presented for Endone prescription, and it was refused. It was noted “discussed doctor shopping” and “no more S8 and S4 medication.” In May and June 2019, OA only collected one prescription for Endone, but 12 prescriptions for paracetamol and codeine (Panadeine Forte). In July and August 2019, OA collected no prescriptions for Endone, but seven prescriptions for paracetamol and codeine (Panadeine Forte). In September and October 2019, OA filled one prescription for Endone, and two prescriptions for paracetamol and codeine (Panadeine Forte).
It is apparent from the dispensing history that OA’s access to Endone dropped significantly from around April 2019, and he was instead provided with Panadeine Forte to manage his pain.
Other medications
In addition to Endone, OA was regularly prescribed other medication to assist with managing his FMF.
As at 14 February 2018, according to Dr Vickers, OA’s medications included:
• Colgout (colchicine) 1 x 500mcg tablets, three times a day;
• Nexium (escemeprazole magnesium trihydrate) 1 x 40mg tablet, twice a day;
• Endep (amitriptyline) 1 x 25mg tablet, in the evening;
• Endone (oxycodone) 1-2 x 5mg tablet, four times a day;
• Naramig (naratriptan) 1 x 2.5mg tablet, as directed;
• Targin (oxycodone and naloxone), 1 x 2.5mg or 5mg tablet, before bed
Dr Vickers also prescribed OA benzodiazepines including diazepam and temazepam or seven occasions throughout 2016-2017. OA was further prescribed benzodiazepines by Dr Carlos Tahuil Ochoa on 1 June 2015, by Dr Reinier De Villiers on 5 November 2016, and by Dr Saima Khalid on 18 February 2017.
Dr Peter Nash, urologist, was also a member of OA’s regular treating team. OA first attended his practice on 1 February 2017 on referral by Dr Vickers. He was commenced on testosterone supplementation which improved his baseline testosterone levels and his libido. He noted that when OA was compliant with his medication, he had improved libido. He used sildenafil (Viagra) at times. OA was also given intra-corporal injections of Caverject with good results.
On 4 April 2019, Dr Nash wrote to Dr Vickers to summarise his treatment, noting that he had not seen OA for nearly 12 months prior to that appointment and consequently OA had not had Reandron (testosterone undecanoate) for more than 12 months. From the letter it appears that OA was supposed to be having Reandron (testosterone, undecanoate) regularly. On this date, OA complained of oesophageal discomfort, diminished libido, and erective dysfunction, which Dr Nash said was not surprising.
Dr Nash prescribed OA with Reandron (testosterone undecanoate) and arranged testosterone level tests. OA was supplied with testosterone undecanoate (Reandron) on 5 April 2019 and 6 June 2019.
On 5 September 2019, Dr Nash again wrote to Dr Vickers and stated that OA had been non-compliant with his testosterone supplementation, and consequently OA again suffered from diminished libido and general lethargy. OA stated to Dr Nash that he was keen to restart the injections and Dr Nash gave him a script for testosterone undecanoate (Reandron), to be injected by Dr Vickers. According to the PBS Summary, Dr Nash prescribed testosterone undecanoate (Reandron) to OA on 5 September 2019, who filled the prescription on the same day at the Community Pharmacy, and a repeat on 21 October 2019.
On 21 October 2019 to 22 October 2019, Dr Vickers noted OA presented with significant anxiety. He did not appear psychotic. He commenced OA on olanzapine 2.5mg for agitation. He was then admitted to hospital in November 2019 and scheduled (and prescribed oxycodone by the hospital). It was recommended he be referred to a psychiatrist on discharge. On 8 November 2019, Dr Vickers observed OA to be “quite delusional” which he felt may have been triggered by a breakdown of his marriage. He continued to be seen and was prescribed olanzapine. He was waiting for an appointment to see Dr Hughes, psychiatrist.
On 8 January 2020, Dr Vickers said he had “increasing concerns that he may have manic depressive illness.” He wrote a treatment plan for OA’s solicitor. On 22 January 2020 he felt he was “much improved”. On 23 January 2020, Dr Nash wrote to Dr Vickers noting for the third time that OA was non-compliant with his follow-up blood tests and regular Reandron (testosterone undecanoate) injections. Dr Nash wrote a further prescription for Reandron (testosterone undecanoate), which OA collected from the Community Pharmacy on 29 January 2020.
In summary, OA had irregular and non-compliant use of Reandron (testosterone undecanoate) from at least 2018.
Change in mental health in October 2019
CA stated that until October 2019, OA had never had issues with depression or anxiety, he did not take drugs and did not drink alcohol. However, around October 2019, OA’s personality changed and as his mental state deteriorated, he became increasingly paranoid and agitated. From this time, CA stated that OA would regularly call the NSWPF to report things that were not happening. OQ began to see things that were not there, visual hallucinations such as cars pulling up in front of his work and flashing lights. He also began displaying paranoid behaviours, such as thinking that CA’s father, was trying to take his business, or that CA had a secret job and was cheating on him.
In October 2019, CA took OA to Dr Vickers who on 22 October 2019 prescribed OA a daily anti-psychotic medication, Zyprexa (olanzapine) to treat OA’s “manic symptoms”.
According to a letter written by Dr Vickers dated 8 January 2020 prepared for OA’s solicitor, it was around this time that OA was diagnosed with bipolar affective disorder, with intermittent depression and mania, and his treatment program involved biweekly visits to Dr Vickers for supportive counselling and review, treatment with the antipsychotic medication Zyprexa (olanzapine, 2.5mg at night, being increased to 5mg), and treatment by a psychiatrist Dr David Hughes, although at the time of his death OA was waiting for an appointment.
On 28 January 2020, Dr Vickers referred OA to Mr Borenstein, psychologist, who saw OA on 11 February 2020. Dr Vickers last saw OA on 10 February 2020 and at that time did not consider him as a suicide risk. He was future oriented, planning to see Mr Borenstein the following day.
Dr Vickers noted that OA was seen by himself and 11 treating specialists. He felt the communication between the various medical practitioners was excellent and comprehensive and he felt supported in the treatment regime. He said OA disengaged from the team after the PSP letter.
Psychologist report of Mr Sam Borenstein dated 11 February 2020
St George Hospital on 1 November 2019. He reported using (snorting) three to four bags of cocaine after discharge from hospital. He was reported to have “symptoms of depression” that were persistent including suicidal ideation with intent. OA reported consuming cocaine. He acknowledged being in a “paranoid state” due to his cocaine use. OA reported being “free of cocaine” at the time of the assessment with “improved sleep patterns, upwards of eight hours per day, a return of normal appetite and weight.”
Interactions with NSWPF in late 2019
Until 2019, OA had only been adversely known to the NSWPF in relation to traffic matters. On 20 October 2019, NSWPF officers attended OA and CA’s home, after a call was made by OA regarding the mental state of CA.
OA spoke with NSWPF officers and informed them that CA had locked herself in the children’s room due to being concerned for his mental health. NSWPF officers spoke with CA and the two children in the bedroom and discovered that a verbal argument had taken place between OA and CA. No Apprehended Domestic Violence Order (“ADVO”) was sought in relation to this incident.
On 25 October 2019, CA drove her child to preschool but decided not to drop her off after noticing OA’s car parked down the road and fearing OA would take their daughter. As CA began to drive away, OA cut her off in his car. OA then removed CA’s keys and went through her bag asking: “what are you hiding from me?”
Later that day, CA, her mother, and her children attended Miranda Police Station. CA’s mother told NSWPF officers that she and her husband were reportedly in fear for the safety of CA after hearing of that day’s incident. The COPS Event notes that CA’s parents were concerned about OA owning all the family assets and reported that OA had made the children say goodbye to CA and engaged in other instances of controlling behaviour, such as tracking her phone. CA was unwilling to provide a statement but stated that OA’s behaviour had only changed in the last month. NSWPF officers observed CA to be scared and they feared for her safety, believing that she was withholding information.
On 1 November 2019, NSWPF officers applied for an ADVO listing CA as the person in need of protection and OA as the defendant. The ADVO was enforceable until 5 June 2020 at which point it would have reappeared before Sutherland Local Court. CA stated that after the ADVO was granted, OA moved out of the marital home and lived at Woronora Caravan Park, however, CA would still cook him dinner and see him every day.
Admission to and Discharge from St George Hospital
On 1 November 2019, CA accompanied OA to St George Hospital as she was concerned about an infection in OA’s leg which was later diagnosed as cellulitis. Due to concerns about OA’s mental state, hospital staff conducted a psychological assessment.
On 2 November 2019, a medical practitioner at St George Hospital examined OA for the purposes of the Mental Health Act 2007 (“MHA”), and noted that he had: “pressured speech, lack of insight into current health issues, paranoid ideas about wife’s infidelity”, and “paranoid delusions of infidelity of wife, visual hallucinations (seeing shadows in the room), hypersexuality (communicated by wife)”.
CA reported to staff that in October 2019, OA had been increasingly paranoid about her supposed infidelity. CA said that other behavioural changes included increased agitation and weight loss. She said that OA would often return home from work at 3:00am and leave again a few hours later. OA’s urine drug screen, as requested by CA, tested positive for cocaine and he admitted to frequent cocaine use in the one to two months prior to admission.
St George Hospital records from this admission note a diagnosis of drug induced psychosis, bipolar affective disorder, and mania with psychotic symptoms.
Professor Sturgess, rheumatologist, who had reviewed OA a few times on a previous admission in December 2016, examined OA on 1 November 2019 and noted that OA’s psychosis was unlikely to be related to FMF.
During treatment, OA was a mentally ill person pursuant to the Mental Health Act, presenting with grandiose ideation, hallucinations, and paranoia. The matters disclosed and discussed by OA while in that mentally unwell state should be considered in that context. OA discussed various stressors in his life including lack of sleep, his belief of his wife’s alleged unsubstantiated infidelity, a failing business facing bankruptcy, similarly uncorroborated, frequent cocaine use and attacks of FMF. OA also discussed the stressor of his wife’s behaviour changing over the past two years and gave examples of her not emptying the dishwasher before wiping the kitchen bench and not vacuuming the floor, but OA was unwilling to elaborate further. None of these matters were rational in keeping with his precarious mental state. While on the ward, OA’s mental state was “quickly stabilised” with olanzapine (Zyprexa).
Dr Jonathon Koh, psychiatric registrar, noted OA “recently attended GP and prescribed olanzapien which patient did not comply with” (sic). It is unclear whether OA told Dr Koh that he was not complying or whether Dr Koh obtained this information through another source.
In relation to pain relief, OA stated that he usually took 2 x 5mg tablets of Endone (oxycodone) multiple times a day, for the pain caused by his FMF, and frequently requested Endone (oxycodone) from St George Hospital staff. At the same time, OA denied recent use of Endone (oxycodone) and said he had ceased taking Endone and colchicine a while ago. At this time, OA’s most recent Endone prescriptions were dispensed on 10 October 2019 and 31 May 2019. CA expressed her concerns to RN Poonam Prakash that OA excessively used Endone (oxycodone) to manage the pain of his FMF. CA said that while she had talked to OA’s GP who made no recent
prescriptions for Endone (oxycodone), she had also recently found an empty Endone (oxycodone) packet in their home.
On 2 November 2019, CA rang St George Hospital for an update and reiterated her concerns to RN Bryan Chan. RN Chan informed her that OA had been given Endone (oxycodone) for pain relief and CA said it was a “long story” and she did not want OA to be given Endone (oxycodone). RN Chan reviewed OA’s history and found no documentation to support not giving him Endone (oxycodone). On the same day, OA commenced taking 2mg of colchicine daily.
On 3 November 2019, when visiting the hospital, CA again told the nursing staff not to give OA any pain relief and stated that OA is highly dependent on pain relief, which is why he constantly requested it. On 4 November 2019, RN Prakash noted a maximum of 25mg of Endone (oxycodone) daily for OA.
CA visited OA on the evening of 3 November 2019. Then, according to CA, OA telephoned her on the morning of 4 November 2019, asking her to come and get him discharged from hospital, and then called again one to two hours later asking her to go to his business to do a task. CA stated that OA said: “go back to work and I’ll give you all the codes for everything and fix it all up. If you can’t get it to work, call the IT guy”. It is unclear what precisely the task was. CA waited for a follow up call, but OA did not call, so she attended the hospital and spent some time with OA.
St George Hospital records note that GA visited OA in the morning of 4 November 2019, and they discussed discharge plans. OA’s discharge plan states his intention to stay with his brother, GA, while he repairs his relationship with CA and gets his business back on track, and it was communicated to OA’s treating team that GA would provide accommodation for OA until required. At some time on 4 November 2019, OA completed a “nomination of designated carer” form, which has two spaces to nominate two different designated carers. OA nominated GA as his “designated carer 1” and made no nomination for “designated carer 2”.
OA’s treating team reviewed him on 4 November 2019 and approved him for discharge that day. OA was then allowed to go on leave and return at 5:00pm to collect his medications, his discharge summary, and belongings. OA’s employee, BP, was at the office with CA’s father, when he received a call from OA in hospital stating that he had been released on a day pass. BP and OA then bought and installed locks on the workshop doors because OA did not trust CA’s family before BP took OA back to St George Hospital, where OA called his brother GA.
GA stated that on 4 November 2019, he received a call from OA in the “Sutherland Mental Health Hospital” (it is assumed that he is referring to the St George Hospital Mental Health Unit) stating: “it was her and her family that put me in here. I don’t trust her or her family. I want to change everything”, referring to CA. OA said to him that CA used the ADVO in place against him and threatened to call the NSWPF and would not let him see his children. OA said to him, crying: “the reason why she put me in here was so that she could take control of all of the assets. Thank you so much for coming to get me GA”. This information, as stated by GA, clearly sits against the reports that were made by CA and her family to NSWPF officers. It appears this statement is further
evidence of OA’s continuing mental health issues. GA of course accepted what he was being told and was concerned for his brother.
• Cefalexin 1 x 500mg capsule, four times a day, to cease on 09/11/2019;
• Colchicine 4 x 0.5mg tablet, once a day;
• Olanzapine (Zyprexa) 1 x 10mg tablet, once a day at night;
• Oxycodone (Endone) 1 x 5mg tablet, four times a day, as required for “breakthrough pain”; and
• Paracetamol 2 x 500mg tablet, four times a day.
Discharge notes record that OA agreed to continue medication and follow up with a private psychiatrist, his regular rheumatologist Dr Joshua and GP Dr Vickers. OA was also referred to Sutherland Acute Care Team (“ACT”) who note: “they were unable to follow up client, he did not return calls. He was DC today as lost to care”. The mental health notes of Sutherland ACT form part of the St George Public Hospital Medical Records which are in the brief of evidence that was tendered in these proceedings.
Following OA’s discharge, BP stated that he and OA went to the workshop at around 6:00pm to catch up on work. BP went home at around 8:30pm, at the instruction of OA. It is unclear how OA intended to get home and whether he did go home. From BP’s statement, it does not appear that GA went to the workshop with them. According to CA, she received a call from Miranda Police Station in the afternoon of 4 November 2019 while picking up one of the children from school. CA states that she was told OA was at the station and that CA needed to return his property to him, which she had been holding while he was in hospital. CA had not been told about OA’s discharge despite being listed as OA’s next of kin, according to her. CA called St George Hospital at around 6:00pm and was told she was not OA’s nominated carer and so they could not discuss the matter with her.
After being told of his discharge, CA drove to OA’s business, but OA was not there. In the days following his discharge, according to CA, OA expressed concerns about his brother, saying: “GA is threatening me and telling me that I have to go his house or else he will put me back in Hospital. He thinks he’s my carer and he’s not my carer”. OA said he was receiving texts and calls from his brother. Again, this is information that was being given to his wife, who accepted his concerns, but again was further evidence of his failing mental health.
On 6 November 2019, CA called the St George Hospital Mental Health Unit and requested that his brother not be given information regarding OA, as OA was staying at the marital home, and was concerned that his brother was going to try and get information about him from medical records. She was advised that OA himself had to call the hospital to make any changes. OA called St George Hospital on the same date
and hospital staff member Angela Crow noted the following: “States that his brother ‘bullied’ him into discharge, and is now calling him stating that he ‘has to’ come live with him, as he is now his carer. Brother apparently stated that he could put [OA] into hospital at any time again and encouraged him to stay away from his wife.” GA stated that a couple of weeks after OA’s discharge, OA came to his house and said: “don’t call me or message me anymore, I will call you”, because CA was checking his phone.
Consequently, GA began speaking with BP, the work colleague of OA.
ADVO Breaches in December 2019
On 5 December 2019, OA breached the ADVO by taking CA’s phone and attempting to unlock it to access data. CA and their two children observed OA to leave the house before returning one minute later with CA’s mobile phone having been destroyed.
At around 6:00pm on 24 December 2019, OA confronted CA in the kitchen of their home regarding her alleged infidelity, in the presence of the children. OA walked upstairs and removed hidden cameras from CA’s bedroom, stating that he had recorded her with other men. When OA put the bag of hidden cameras down, one of the children attempted to grab the bag and run away. OA caught the child trapping her arm in a door and grabbed the bag from her, striking her lip with his fist as he did. A scuffle ensued and OA later left the residence. CA reported this incident on 26 December 2019 at Sutherland Police Station. One hidden video camera was produced to NSWPF, but no recorded files were saved to it. The fact that the camera did not in fact contain any recorded footage may indicate that OA suffered from delusions in the period preceding his death.
At midday on 25 December 2019, OA attended the home where the children were spending Christmas. CA stated that at this time OA still resided at the marital home, but that he no longer had keys and CA did not allow him inside when she believed he had used drugs. OA argued with CA at the front door. OA later attended Miranda Police Station to obtain a police report number for this incident, on the advice of his solicitor.
At around 11:45pm on 25 December 2019, NSWPF officers attended the home at the request of CA after OA forced his way into the house and argued with her about seeing another man.
BP stated that between Christmas and New Year, OA would call him between 10:00pm and 1:00am and ask BP to drive him to CA’s house to catch her cheating, because BP’s car was quieter than OA’s. OA would call repeatedly until he picked up or just show up at his house. On two occasions, BP drove OA over to CA’s house where OA would get out of the car, walk around the house, and then get back in the car. NSWPF officers attempted to make contact with OA, and on 27 December 2019, OA’s lawyer contacted NSWPF stating that OA would attend Sutherland Police Station on 30 December 2019.
CA stated that she contacted NSWPF on 30 December 2019 as OA was putting cameras around the house. At 9:50am on 30 December 2019, OA attended Sutherland Police
Station and was arrested, cautioned, and escorted to the charge room. OA declined to be interviewed and was charged. BP received a phone call from a female NSWPF officer a day or two after their last night-time drive to the home. The NSWPF officer said that OA was in “Surry Hills Police Station”, and he wanted to pass on a message to BP to “protect the business”. CA stated that she did not want Oa to be charged, but for him to be provided with mental health support. OA was released from custody on 31 December 2019.
Early 2020
OA continued to contact CA, calling her 120 times on one occasion. OA was transitioning to living in a caravan park in Woronora until the court case was resolved.
In January 2020, OA collected prescriptions for paracetamol and codeine (Panadeine Forte), and olanzapine (Zyprexa) as prescribed by Dr Vickers, but he is also recorded as attending a pharmacy on three occasions to collect oxycodone (Endone) as prescribed by a doctor called Dr Muhammad Faisal. During this time, he also collected a prescription for testosterone undecanoate (Reandron) as prescribed by Dr Nash and previously discussed.
In February 2020, the only medication OA collected was a testosterone prescription (a different PBS item to testosterone undecanoate), which had been prescribed by Dr Vickers in August 2019.
Between OA’s discharge from hospital on 4 November 2019 and his death, according to the Medicare Patient Summary, OA attended Dr Vickers for Mental Health Treatment on 8 November 2019, 13 January 2020, 22 January 2020, 28 January 2020 and 10 February 2020. On 31 January 2020, OA attended a GP, Dr Ryan Shannan, but does not appear to have any prescription arising from this consultation.
As at 28 January 2020, according to Dr Vickers, OA medications included:
• Colgout (colchicine) 2 x 500mcg tablets, three times a day;
• Diazepam 1 x 5 mg tablet, in the evening;
• Humira (adalimumab) 20 mg/0.4mL prefilled syringe, as directed;
• Keflex (cephalexin) 1 x 500mg capsule, three times a day;
• Nexium (escemeprazole magnesium trihydrate) 1 x 40mg tablet, twice a day;
• Norvasc (amiodipine cesylate) 1 x 5mg, once a day;
• Panadeine Forte (paracetamol and codeine) 1-2 x 30 mg tablet, four times a day;
• Temaze (temazepam) 1 x 10mg tablet, before bed;
• Testogel (testosterone) 4 x 12.5mg pumps, daily;
• Zolfran Zydis (ondanselron hydrochloride) 1 x 8mg wafer, twice a day; and
• Zyprexa (olanzapine) 1 x 5mg tablet, before bed.
In mid-January 2020, OA told BP that he wanted to open a new business and move the assets over to it and transfer the deed on his car to his best friend, in order to prevent his possessions being taken.
On 15 January 2020, NSWPF attended the business premises, and spoke to OA and CA in order to ensure they were compliant with their ADVO conditions. OA and CA were both working at the premises on this date.
In February 2020, OA was increasingly paranoid about CA cheating on him and would go to BP’s house between 1:00am and 4:00am about four to five times a week and call him every day after work.
All of these events highlight the severity of his mental illness, and his deterioration. It is also the case that at this time OA was not prescribed Endone, although reported that he was using it, presumably obtaining it from an unknown and unauthorised source.
Prescription shopping
Due to his FMF, OA regularly saw a range of known doctors including his GP, Dr Vickers, and specialist physicians Professor Wakefield, immunologist, Dr Nash, urologist, and Dr Joshua, rheumatologist, who were in communication with each other. OA was prescribed a range of medications by these doctors including Endone (oxycodone) for pain relief.
However, OA was also prescribed Endone (oxycodone) by a range of other doctors. By at least 13 March 2019, Dr Vickers, Professor Wakefield, and Dr Joshua had received correspondence from the Prescription Shopping Information Service regarding OA “doctor shopping”. It does appear that the regular treating team strictly limited OA’s Endone (oxycodone) from this point.
The Prescription Shopping Program (“PSP”) is a program available to medical practitioners in order to minimise prescription shopping. Patients are flagged in the service if, in any three-month period, they receive excessive medication as set out in a schedule.
If the patient meets the above criteria, the PSP can provide a practitioner with a summary of the PBS items supplied, and a PSP Summary Report of the PBS medicines supplied in a three-month period. The PSP includes an information service (“PSIS”) and an alert service (“PSAS”). The PSIS can be called by doctors, pharmacists, dentists, nurse practitioners, and midwives. If the patient does not meet one of the above three
criteria, then the medical practitioner is simply told the patient does not meet the criteria and no other information is provided.
Events preceding death – 12 February 2020 OA drove CA to the Gap
On the morning of 12 February 2020, OA called CA and asked her to meet him to talk, and they sat in CA’s car and talked for about two hours. According to CA, OA told her he wanted to get rid of BP who had stolen “more stuff” from him. This was totally without basis.
BP recalled that on the night of 12 February 2020, OA came to his house for about 30 minutes and discussed with BP the thought that CA was cheating on him.
Although there is some inconsistency in the dates of whether his wife or his employee was with him, nothing turns on that and I accept that information is affected by memory.
Late in the afternoon of 12 February 2020, CA met OA at the caravan park where he was living, and CA got into his car. OA told CA they would be going on a drive to talk, which is something that they used to do. During the drive, OA stopped at a service station, bought some water, and took an unknown amount of his Zyprexa medication. OA also discussed his thoughts that CA was seeing other men and had a secret job.
At around 10:15pm, according to the P79A Report, OA parked outside the lighthouse located on Old South Head Road, Vaucluse. CA stated that OA stopped the car, got out, came over to the passenger side and kept making paranoid remarks. CA exited the car and CA turned back to get her phone from the car and when she turned around again, she couldn’t find OA. The conversation between OA and CA as recorded on the COPS History was that OA said: “You don’t want to be with me”, exited the vehicle and said “I love you” before running to the fence line at the cliff.
The initial triple zero call was made by CA’s sister at 10:10pm where she said that OA had threatened to throw himself off the Gap and then ran off. There was an error noted in the caller record, but I accept this was in fact made by OA’s wife’s sister.
CA received a call from the NSW Ambulance phone operator at 10:16pm and she told them that OA had taken Zyprexa and Valium, then ran off.
Arrival of NSWPF
Constable Goonewardene began to patrol the parkland. Due to poor visibility, rain and thick shrubs, Senior Constable Haigh requested “POLAIR” at 10:31pm, but was told it was unavailable. At 10:34pm, Senior Constable Davis requested the NSWPF Dog Squad to assist in the search. At 10:35pm, Senior Constable Haigh requested the NSW Ambulance Helicopter to assist with the search.
They had received a radio broadcast regarding the incident at around 10:15pm.
The conditions were noted as raining, windy and cold, and Senior Constable Nichols and Senior Constable Craig headed towards the lighthouse area with roping bags, search lights and a Suicide Intervention Kit which contains a rope, a belaying device, and a rope anchor with a carabiner.
At 10:37pm, Senior Constable Nichols and Senior Constable Craig located OA sitting on the cliff face, beyond the 1.5 metre security fence. According to Detective Sergeant Devereux, upon sighting them, OA moved down the cliff face. Senior Constable Nichols stated that he found OA crouching on the sides of the cliff about 2 metres down, and Senior Constable Craig communicated this via radio to the other NSWPF officers. Senior Constable Nichols put his harness on and asked Senior Constable Craig to set up the Suicide Intervention Kit. Senior Constable Nichols asked the name of the man and was told “OA”. It also appears that Senior Constable Nichols was informed by radio that OA had taken some tablets and made suicidal threats. It is unclear whether the involved NSWPF officers were informed that OA had bipolar disorder.
At 10:44pm, Senior Constable Nichols went down the cliff. Senior Constable Nichols asked OA if he was okay, and OA nodded. Senior Constable Nichols then said: “I’m going to come down near you to chat as I am worried about you” and climbed down the next level into a small cave just below the cliff edge and above OA. Senior Constable Nichols lay down on his stomach and began talking to OA, asking him several times to come back up. OA responded several times: “I will but I need ten minutes”.
Senior Constable Nichols offered to come down and help him up, but OA said no. OA’s eyes were closing as though he was falling asleep, his head would occasionally droop as if he was falling asleep and Senior Constable Nichols was concerned that OA could slip at any point given the rain. When OA’s head would droop, Senior Constable Nichols would say “[OA] don’t fall asleep, it’s not safe to fall asleep here”.
According to Constable Flynn, Acting Inspector Barrett was the Duty Officer on scene.
Senior Constable Craig recalled that at one point Senior Constable Nichols said: “he could be back up soon” and Senior Constable Craig relayed that information to the Duty Officer, Acting Inspector Barrett. Around this time, Senior Constable Craig called the NSWPF Rescue Base and informed Senior Constable Christopher Wills of the situation and that they may need additional NSWPF Rescue resources to attend.
At one point, as OA’s head drooped, Senior Constable Nichols tapped him on the top of his head and said his name. OA looked up at him and Senior Constable Nichols said: “I am sorry for touching you. I needed you to wake up, I was worried you were going to fall”. Senior Constable Nichols stated that at this point OA started looking over his shoulders in a paranoid manner and asking: “who’s there?”. OA asked Senior Constable Nichols to shine his torch onto a tree on the cliff and OA began rustling the bush with his hand.
Senior Constable Nichols made a loop for OA to grab hold of, but OA did not grab it. In his directed interview, Senior Constable Nichols recalled saying: “come up to the top and I’ll fuck off and leave you alone, I just want you away from the cliff edge”.
OA said: “you shouldn’t have come out here”. Senior Constable Nichols said: “This is my job and I need you to come back with me” and continued to ask OA to come back up the top. At one point, OA said: “I can’t, my leg is sore”, and after several minutes, OA finally agreed to let Senior Constable Nichols come closer to assist him.
Senior Constable Nichols then yelled up to Senior Constable Craig (it does not appear they were in communication by radio): “I am going down closer to him. Pay out the line so I can move closer” and climbed down closer to OA. Senior Constable Nichols squatted down next to OA and told him he would place the tape around him to ensure he was safe. Senior Constable placed the tape around OA’s back, but as he was about to get the other end of the tape over OA’s body, OA pushed it away. Senior Constable Nichols said: “don’t do that, I just need to secure you so you don’t fall mate”, and OA pushed Senior Constable Nichols’ right shoulder and leant backwards. Senior Constable Nichols grabbed OA’s right arm and right shoulder/shirt. Due to the rain, OA’s arm was slippery, and his shirt ripped at the seam, and OA slipped from Senior Constable Nichols’ grip and fell into a tree around 2 metres below. This tussle and subsequent fall are corroborated by the recollection of Senior Constable Craig who was watching from above and appears to have occurred at around 11:21pm.
After remaining still for some time, OA then started moving around and appeared to Senior Constable Nichols to be trying to free himself as though he was entangled in the tree. Senior Constable Nichols yelled out: “stop moving, you will fall, we will come and get you”. After a few minutes, OA appeared to fall asleep in a seated position, twitching at times. Senior Constable Nichols decided not to yell out and startle him. OA appeared to be asleep for between 5 to 10 minutes while in this precarious position.
Senior Constable Nichols updated Senior Constable Craig and advised that they needed further operators to attend to perform a rescue on the cliff edge. The reasons for needing further operators, as stated by Senior Constable Nichols, were that the location where OA was situated was unknown, Senior Constable Nichols did not know
what was below OA, OA had been somewhat combative during the previous intervention, and the standard operating procedures require NSWPF Rescue officers to have multiple operators for a vertical cliffside rescue. Senior Constable Nichols stated that in these circumstances, he would require one further operator on ropes with him, a supervisor on the top for edge safety and a further operator to physically haul OA up the cliff if required. Senior Constable Craig relayed this information to the Duty Officer, Acting Inspector Barret and again spoke to Senior Constable Wills stating that they would require further NSWPF Rescue resources. At the top of the cliff, Senior Constable Craig had arranged for the other NSWPF officers including Senior Constable Haigh, Senior Constable Davis, Senior Constable Goonewardene and (the recently arrived) Acting Sergeant Simon Noss to bring all the roping resources, and to drive one of their NSWPF vehicles to the fence line in order to set up lines from the truck.
After five to ten minutes, OA awoke and began attempting to free himself from the tree, and Senior Constable Nichols called out “stop” and OA looked up, suddenly rolled to his right and disappeared over the edge. Senior Constable Nichols called out “he’s gone” up to Senior Constable Craig.
About two seconds later Senior Constable Nichols heard the thud of OA hitting the ground. Records state that OA fell down the cliff face at around 11:42pm. NSWPF negotiators had not yet arrived at this time, but according to the CAD log it appears they had been calling a user called “ES10”, but their calls were going to voicemail. From the COPS History, ES10 is linked to “Barrett”, who is likely Acting Inspector Barrett.
The conclusion of the rescue
Senior Constable Nichols returned to the top of the cliff and spoke with the other NSWPF officers and NSW Ambulance paramedics. They discussed the feasibility of a NSW Ambulance rescue helicopter attending, as they were unsure whether OA was alive, as they were unable to see him. Senior Constable Nichols stated that they were advised the helicopter was unable to attend due to the weather, and so they decided that Senior Constable Craig would belay down the cliff to assess OA. It appears from Senior Constable Nichols’ directed interview that further officers from NSWPF Rescue Unit had attended at this point, including Senior Constable Christopher Wills, Senior Sergeant Michael Smith, and Senior Constable Jervis (first name unknown), who assisted in belaying Senior Constable Craig down the cliff.
Senior Constable Craig stated that OA was laying at the bottom of the 90 metre cliff, just metres away from where the waves were breaking. Senior Constable Craig found OA had no pulse, was not breathing and confirmed he could not be revived.
Senior Constable Craig had lost phone and radio reception, and so he proceeded to an elevated rock shelf and attempted to broadcast information back to the NSWPF officers at the top of the cliff.
attendance including Senior Constable Brett Taylor and Rescue Co-ordinator Senior Sergeant Michael Smith. They decided to haul the body back up the cliff face and Senior Constable Wills abseiled to the rock shelf to assist Senior Constable Fogarty.
During the recovery effort, a rope was cut on the rockface, and the decision was made that given the danger presented they would recover him during daylight hours for safety reasons. NSWPF Rescue Unit retrieved OA’s body on 13 February 2020 with the assistance of a NSWPF helicopter.
The incident was declared a critical incident at around 12:37am on 13 February 2020.
NSWPF response
Evidence in the proceedings Detective Senior Constable Blair Joynson
Sergeant Luke Barrett
Sergeant Barrett (who was Acting Inspector in 2020) was in effect in charge of the operation at that scene. He was in contact with the state coordinators to raise more resources. He was responsible for the rescue attempt. He noted that when he attended, which was when the incident was already attended by police, there were limited lights, it was overcast, cloudy, the weather was poor, rain had started, and he was faced with police crews trying to provide light up the cliff face.
There were a number of crews that he was responsible for. He quickly formed view that this was likely a fall or jump, properly assumed mental health issues, and was concerned about the lack of continued communication by OA. He placed the call to negotiators but noted that they take some time to attend, particularly at that time of night, where they would be coming from their homes being on call. He also noted that the negotiators do not perform the same role as the active rescue team. Rescue operatives perform the negotiation task in precarious safety situations such as in this case. They make an assessment of what they can do to open up lines of communication.
Sergeant Barrett acted quickly to coordinate the scene, made appropriate and timely calls, prioritised his responsibilities and did his best in the difficult circumstances.
Professor Denis Wakefield
Professor Wakefield is a Professor of medicine at UNSW and Consultant Physician and is the Director of Immunology. He was treating OA who he noted was suffering from a very rare disease. He noted that usually the disease is identified in a much younger person. He had only seen 4 patients in his career with the condition, highlighting the rarity.
He noted that at the time there were limited treatments available. In effect there were only 2 usual medications, and OA was resistant to both. Application was made to access other drugs not part of the PBS on compassionate grounds in an attempt to help him. He was in constant pain, and the pain was telling the medical professionals that the disease was not properly controlled. As a result, he was prescribed pain relief to allow him to try and function in his daily life.
He noted that the attendance of OA at appointments dropped off after the doctor shopping came to light. He also believed that OA had a reluctance to see a pain management specialist.
He noted the tragedy of this case and indicated that today there are better medications available that were not readily available to OA. He noted that everyone involved in OA’s medical care wanted to do the best, however, they were very limited in what was available.
Dr Rowan Vickers
Dr Vickers was OA’s General Practitioner (“GP”) for 13 and a half years. He noted that he had three major presentations of FMF, mental health, and low testosterone. He noted that in 2006 he presented with extremely severe headaches and described them as brutal. He investigated using MRI and CT, but ultimately, he required pain relief in the form of prescription medication. This situation settled, as it would seem did many of his early “flare ups”.
At a later time, OA presented with complaint of low libido, which disclosed a low testosterone level, which appears on all medical evidence to be unrelated to the FMF. It was not until 2016 that FMF was identified. He noted that as the pain was addressed OA developed a tolerance, as is usual, to the pain relief, which meant that he required a higher dose to obtain the same level of relief. As his GP, he indicated that he had no inkling that OA was prescription shopping, and that now with the development of SafeScript this could no longer happen. The first time he was advised was via the letter he received, he had never received such a notification and believed that all doctors involved in his care would have received the notification.
He noted that in the course of treatment, when OA’s pain was not as severe, they would try and reduce the pain killers. He also gave evidence that doctors do not
like the constant prescription of these forms of drugs, and work with patients to reduce intake where possible.
Dr Peter Nash
Dr Nash is a Urological Surgeon. OA first attended his practice on 1 February 2017 after referral by Dr Vickers. He gave comprehensive evidence about OA’s pituitary condition resulting in low testosterone. He indicated that it was likely an isolated genetic defect with no link to FMF.
He gave evidence that new research is indicative of low testosterone levels being linked to low mood, and in cases of depression that people ought sometimes be tested for a low serum testosterone which may have an impact on their mood.
He noted that OA required treatment to maintain an appropriate testosterone level, which he was only semi compliant with. OA provided no information to Dr Nash about reluctance to accept the treatment, and Dr Nash expressed some surprise given usually the patient did find relief as a result of the treatment and so would continue to seek it out. He noted that when non-compliant OA’s testosterone would have fallen, weight gain would have likely occurred, and libido too would have suffered.
Dr Frederick Joshua
Dr Joshua is a very experienced Rheumatologist. He diagnosed OA with FMF and noted it as a very rare condition, and in the case of OA he sought out collaboration with Dr Wakefield. He noted that OA was in acute pain. The pain was both abdominal and joint pain, with the most debilitating of those being the severe abdominal pain. It was an inflammatory condition that can lead to serious harm, such as organs being affected, and, in particular, kidney disease. OA was already experiencing stage 1 kidney disease.
The method of treatment for FMF was around treatment trials, to test what best worked. As outlined above a number of drugs were trialled, even moving to non PBS on compassionate grounds. He described it as a trial and error approach, constantly investigating and monitoring him.
He noted that although cocaine use would not likely affect the pain levels, it may have altered his psychological state.
Dr Kerri Eagle
induced psychotic disorder, particularly when OA presented to hospital in 2019 and was scheduled. She noted that susceptibility to a psychotic disorder can be a multifactorial issue, it can result from biological factors, genetic factors, or environmental factors.
Dr Eagle noted that the more you are exposed to a drug such as cocaine the more chance to develop psychosis, and once you experience a psychosis, as a result of reaction to a drug, you are more likely to have more significant psychotic effects the more exposure that you have. The brain can experience damage and from there it will become more pronounced with each exposure and more difficult to treat.
She noted that oxycodone myalga although not life threatening is generally very unpleasant. It makes it difficult to sleep, flu like symptoms can develop and the lack of energy is significant. An individual is also more susceptible to low mood.
Dr Eagle did a thorough and independent review of the hospital treatment in relation to the schedule in November 2019. She noted a few inconsistencies with procedure, however, overall considered that OA was properly diagnosed and treated while at the hospital.
OA had nominated his brother as the designated carer, leaving blank the second designated carer. Her only comment that I would refer to in passing is that her view was that an opportunity was missed to inform CA of OA’s release. She indicated that the change to the legislation, and in particular, the provision of s. 72A of the Mental Health Act provides that the principal care provider could and should have been notified. The reforms to the legislation are present to assist in cases just like this one. CA was clearly involved in his care, the notes disclosed they were married, that he was residing in the family home and things had escalated to the point of and ADVO being in force. Dr Eagle was of the view that it would have been prudent to do so.
OA’s paranoia related to concerning beliefs about his wife, which was consistent with his illness. For both his and her safety Dr Eagle in effect would have preferred a cautious approach to ensure that his wife was simply informed of his discharge.
His wife became aware within the hour of his discharge, and consistent with the comments above he returned very quickly to be with his family. Although nothing of significance in this case turns on that, it is a good opportunity for a reflection on general practice.
Conclusion
relief and very potent and addictive pain killers. It is unsurprising that he sought out more and more pain relief in an attempt to help himself function in his day to day life.
He also turned to cocaine use, which as Dr Eagle points to is sadly not uncommon for a person experiencing pain and low mood to self-medicate.
OA had a supportive medical team, who worked very diligently to find a solution for him. He too was committed to the betterment of his health and spent time, effort, and money to try and achieve an outcome that would allow him to live his life, be with his family and work in his business.
At the point of his death, OA was suffering from psychotic thoughts as a result of his drug addiction to the prescription pain killers, he was barely able to stay awake even on the edge of the cliff.
In the dark and rain, in terrible weather conditions they did their best to assist him in his time of crisis. They did not give up, even when they almost had him, they stayed with him, Senior Constable Nichols and Senior Constable Craig worked as a team.
Senior Constable Nichols was kind, spoke with OA while he himself was in a precarious position. His focus was to save the life of OA. When OA fell there was no hesitation. He immediately scaled the cliff to discover if there was any chance of saving OA. The team did their best that night and were able to bring OA back from the cliff, even if only for his family.
FINDINGS Whether OA’s FMF, associated pain and other medical conditions were adequately managed and the impact on OA of his use of Endone (oxycodone)
I find that OA’s FMF, associated pain and other medical conditions were adequately managed.
Endone addiction became a complex issue for OA as he fought the pain of his condition. The prescription of the same was appropriate in a situation where all was being done to address his condition, in a situation where there were limited treatment options at the time. This situation has changed, but sadly not in time to assist OA. The treating team could not have anticipated that OA would start to seek out the drug, and as soon as they became aware steps were taken to limit his prescriptions. Again, today that process would have occurred much faster with the present systems, and I have no doubt that the doctors now would have been in a position to assist OA with immediacy.
His treating team who gave evidence: Dr Vickers, Professor Wakefield, Dr Nash, and Dr Joshua were all committed to OA’s health and wellbeing. They took extensive steps to treat his conditions and even tried treatments which were relatively new.
They each gave compelling evidence at the inquest, and it was clear that they had done all they could to assist him.
Whether the care and treatment received by OA at St George Hospital between 1 November 2019 and 4 November 2019 was adequate and appropriate
I find that the care and treatment that OA received at St George between 1 November 2019 and 4 November 2019 was adequate and appropriate.
There were areas for improvement, as discussed above, and in particular highlighted by the expert Dr Eagle, but she indicated room for consideration and improvement as opposed to any criticism of treatment.
Whether the response of the NSW Police Force response to OA’s attendance at The Gap on 12 February 2020 was adequate and appropriate
I find that the NSW Police Force response to OA’s attendance at The Gap on 12 February 2020 was adequate and appropriate as discussed above.
I find that the attempts undertaken by NSW Police Force officers to engage OA in discussion and negotiation once they had located him on the cliff face at 10:37pm was an appropriate response to attempt to help OA in the emergency situation that he presented himself.
I find that the attempts undertaken by NSW Police Force officers to contact the NSW Police Force Negotiation Unit and procedures in place to ensure that the Negotiation Unit can readily contact NSW Police Force officers present at the scene was also done, as discussed above, appropriately.
I find that the relevant NSW Police Force Standard Operating Procedures (“SOPS”) or policies were adhered to.
Whether OA’s death was intentionally self-inflicted
I find that although OA went with some intention to potentially self harm, at the point that he left the cliff face the evidence would suggest that it was a fall, as opposed to a decision made to leave the ledge. He was heavily intoxicated on substances as evidenced by the toxicology report and the objective evidence and was finding it difficult to remain awake.
The evidence described an initial fall to a lower ledge, and then an entanglement with a tree, where he appeared to fall asleep, it was only once he woke that he appeared then to roll from the safety of the tree branch, but at that point in time it could not be determined that he intended to fall from the tree.
Findings required by section 81(1)
The identity of the deceased
Date of death
Place of death
Cause of death
Manner of death
Recommendations
Acknowledgements and concluding remarks
I acknowledge the profound loss, continuing anguish, and heartbreak that OA’s family and friends are grappling with as a result of his very tragic passing. I offer my sincere and respectful condolences for their difficult loss.
I would like to also acknowledge and thank OA’s family and friends for their engagement, contribution, and participation to this inquest and throughout the coronial investigation.
I hope that OA’s memory has been honoured by the attentive examination of the issues during the inquest.
I also wish to acknowledge the emotional toll on the police officers who attempted in very difficult circumstances to rescue OA from the cliff face, and the clinicians who tried earnestly to treat OA’s FMF, associated pain, and other medical conditions.
Thank you to the team assisting for a very thorough presentation of this inquest, and thorough exploration of the issues.
Magistrate Erin Kennedy Deputy State Coroner, NSW State Coroner’s Court, Lidcombe 22 March 2024
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