Deceased
Mohamed Rahmathullah Syed Ahamed
Demographics
33y, male
Coroner
Decision ofDeputy State Coroner Ryan
Date of death
2023-02-28
Finding date
2025-02-05
Cause of death
gunshot wounds to chest and upper arm
AI-generated summary
A 33-year-old man with bipolar disorder on reducing doses of risperidone experienced a psychotic relapse and stabbed a stranger at a railway station. He then entered a police station with a knife, advancing on officers despite being ordered to drop it. A police officer discharged his firearm, causing fatal chest and upper arm wounds. The coroner found the officer's use of lethal force was justified and consistent with policy. The patient's GP management, including gradual risperidone dose reduction despite lack of psychiatric review, was deemed appropriate. The police officers' decision not to seek mental health assessment on 26 February 2023 was reasonable under the circumstances, though the coroner noted a systemic need for health-led rather than police-led responses to mental health crises in NSW.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
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Inquest into the death of Mohamed Rahmathullah Syed Ahamed
4 November 2024 — 8 November 2024
5 February 2025
NSW Coroners Court Lidcombe
Magistrate Elizabeth Ryan, Deputy State Coroner
CORONIAL LAW - death as a result of police shooting — was police use of force consistent with policy and training — was police response in preceding days appropriate — was medication prescribed by deceased person’s doctor appropriate.
2023/66886
Counsel Assisting the Inquest: R Ranken of Senior Counsel with C Newman of Counsel, instructed by the NSW Crown Solicitor.
The Commissioner of the NSW Police Force: A Richards of Counsel i/b NSW Police Force Office of the General Counsel
Senior Constable J Hotham: L Fernandez of Senior Counsel i/b Anderson Boemi Lawyers
Constable S Morsi and Constable C Jaksa: D Nagel of Counsel i/b Police Association of NSW
Dr A Hameed: M Hutchings of Counsel, i/b Avant Law
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Anamed
Non publication orders Non-publication orders made on 4 and 7 November
i 2024 prohibit the publication of certain evidence. The ‘orders can be obtained on application to the Coroners | ‘Court registry.
Findings Identity |
‘The person who died is Mohamed Rahmathullah Syed
‘Ahamed i
Date of death: Mohamed Rahmathullah Syed Ahamed died on 28 i February 2023 !
Place of death: Mohamed Rahmathullah Syed Ahamed died at Westmead Hospital, Westmead NSW
icause of death: ‘Mohamed Rahmathullah Syed Ahamed died as a result’ of gunshot wounds to his chest and upper arm
‘Manner of death: Mohamed Rahmathullah Syed Ahamed’s death ‘occurred as a result of a police operation
Section 81(1) of the Coroners Act 2009 (NSW) [the Act] requires that when an inquest is held, the Coroner must record in writing his or her findings as to various aspects of the death.
These are the findings of an inquest into the death of Mohamed Rahmathullah Syed Ahamed.
Introduction
Mohamed Rahmathullah Syed Ahamed died at Westmead Hospital in the early hours of 28 February 2023.
Shortly after midnight on 28 February 2023, Mr Syed Ahamed had walked into the foyer of Auburn Police Station. He was holding a knife, and he did not put the knife on the ground when police directed him to do so. Instead he continued to advance on two police officers, Constable (now Senior Constable) Joshua Hotham, and Probationary Constable (now Constable) Sheimaa Morsi. Mr Syed Ahamed died shortly after being shot by Senior Constable Hotham.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
An inquest into the circumstances of Mr Syed Ahamed’s death is mandatory pursuant to sections 23 and 27 of the Act. This is because Mr Syed Ahamed’s death occurred ‘as a result of a police operation’.
A Critical Incident Investigation Team investigated the circumstances of Mr Syed Ahamed’s death, led by Detective Chief Inspector Paul Smith. The police officers of this team are not part of the Auburn Police Area Command to which the involved police officers were attached.
The issues at the inquest
At the inquest the following issues were examined:
Was Mr Syed Ahamed suffering from an identifiable mental illness or mental health condition at the time of his death? If so, did it affect his behaviour immediately prior to his death?
Was the medication which Mr Syed Ahamed’s general practitioner prescribed to him adequate and appropriate? In particular, was it appropriate to have reduced his dosage of Risperidone without advice from a psychiatrist?
Did police officers interact appropriately with Mr Syed Ahamed on 25 and 26 February 2023?
On 28 February 2023, was there any alternative to the use of lethal force by police? Was their response consistent with NSW Police Force policy and training?
At the inquest, a number of witnesses gave evidence in relation to the above issues. In addition to police and civilian witnesses, these included the following expert witnesses:
Dr Kerri Eagle, consultant forensic psychiatrist Dr Pieternal Sonia van Nieuwenhuijzen, pharmacologist
Sergeant Matthew Genders, NSW Police Force Weapons and Tactics Policy and Review Section
Acting Superintendent Kirsty Hales, Acting Commander of the Mental Health Command, Capability Performance and Youth Command.
Mr Syed Ahamed’s life
Mohamed Rahmathullah Syed Ahamed was born on 31 January 1990 in the town of Adhirampattinam, in the Indian state of Tamil Nadu. His parents are Umer Syed Ahamed (deceased) and Amina Ammal Syed Ahamed. Mr Syed Ahamed has an older brother Abdul Hafeel Syed Ahamed, and two older sisters Masootha Syed Ahamed and Mohamooda Syed Ahamed.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
|MrSyed Ahamed’s family described him as a happy person, who loved sport and was very attached to his family. After finishing secondary school in Chennai he completed a Bachelor of Science degree in 2010. He then moved to the United Kingdom and commenced a business-related course. He did not complete this course however, returning to his family home in India in 2013.
Mr Syed Ahamed married soon after his return to India. However the couple divorced approximately eight months later. Mr Syed Ahamed began to suffer depression and sleep difficulties, and he consulted a psychiatrist in Chennai whose first name is Balan. Dr Balan prescribed medication for Mr Syed Ahamed.
It is not known if he formally diagnosed him with any disorder.
One of his reasons was to earn money for his extended family in India, to assist with their education expenses. He eventually received a bridging visa, after he made an application for a protection visa. This application had not been resolved at the time of his death.
Mr Syed Ahamed’s life in Australia
Despite Mr Syed Anamed having lived for over three years in Australia, little is known about his life here. He did not appear to have close friends, and his family in India had limited knowledge of his Australian life.
For the most part, Mr Syed Ahamed lived in shared accommodation in the Auburn area. One of his house mates described him as ‘a very good man and very softly spoken’, who did not associate much with others in the house.
In June 2020 Mr Syed Ahamed commenced work as a cleaner and kitchenhand with a food processing business, ‘My Muscle Chef’. He was considered to be a hard worker and he remained there until September 2022. After a brief period working with another company, Mr Syed Ahamed returned to work at ‘My Muscle Chef on 12 November 2023.
At the time of his death Mr Syed Ahamed was living in a house with seven other men of Indian background. He shared a room with Mr Arslan Ahmad, who described Mr Syed Ahamed as a strict Muslim who prayed five times a day.
MrArslan Ahmad gave evidence at the inquest. He told the court that sometimes he would wake in the night and hear Mr Syed Ahamed crying. At first Mr Syed Ahamed would not tell him why, but later he said it was because his family was ‘very selfish’, and that he sent money to them. Despite this his family would not tell him anything, and were not responsive when he told them he wanted their help to marry again. Mr Ahmad said that Mr Syed Ahamed had no money and that he himself occasionally gave him some. He described Mr Syed Anamed as ‘sad and depressed and hungry’.
Mr Ahmad also told the court that about ten days before he died, Mr Syed Ahamed was not behaving normally. He was expressing fear that his older
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
brother in India would come to Australia to arrest him and take him to India to be killed.
Pians for a second marriage
Mr Syed Ahamed’s death took place against the background of plans for him to return to India to remarry. However the evidence reflects differences between what Mr Syed Ahamed'’s family told police about these arrangements, and Mr Syed Ahamed’s own understanding of them.
According to his family, Mr Syed Anamed had asked his mother and sister to find a suitable bride for him in India. Although it appears that a prospective bride was identified, Mr Syed Ahamed’s family were not certain that the marriage would proceed. His brother told police that Mr Syed Ahamed ‘expressed his satisfaction with the girl that was arranged to be his bride’, but that arrangements for the wedding could not commence until Mr Syed Ahamed returned to India. Mr Syed Ahamed’s sister Mohamoodha stated that according to her understanding, once the marriage had taken place Mr Syed Ahamed would return to Australia with his new wife.
However, what Mr Syed Ahamed told others about the proposed arrangements does not reflect the above. Mr Syed Ahamed spoke a number of times about this to his general practitioner, Dr Aslam Hameed, whom he attended regularly.
DrHameed gave evidence at the inquest. He told the court that Mr Syed Anamed reported frequent arguments with family members about matters which included the proposed marriage. Mr Syed Ahamed said that his family was putting significant pressure on him to return to India on a permanent basis. However he was very clear with Dr Hameed that although he did want to get married, he wanted to live in Australia, earn good money and ‘live like Australian people’.
As will be seen, on 26 February 2023 Mr Syed Ahamed also spoke with Constables Connor Jaksa and Sheimaa Morsi about the marriage plan. In this conversation he expressed frustration that his older brother would not send him a photograph of the proposed bride, saying:
‘Give photo if | like, | marry her. If! don’t like, I'm not marry her. But they don’t want to show the photo’.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
He did not take the flight.
Mr Syed Ahamed’s 000 call on 25 February 2023
‘T want to complain because | have mental thoughts that, from some people, community people, some people, I’m very, very, very, very mental torture from last two years’.
‘,.. because I'm | have too much torture because they are, they don’t want to get married, in my hometown so they are too much torture and I’m very very, very upset’.
He also said that he was not planning to harm or kill himself.
The operator told Mr Syed Ahamed that she would send a police car. A police computer entry was made, requesting that Auburn Police attend his address on anon urgent basis.
At 4.23am an Auburn police vehicle did attend Mr Syed Ahamed’s address, but the officers could not raise anyone there. The computer entry was updated for police to attend later that morning.
On the afternoon of 26 February 2023, Probationary Constable (now Constable) Sheimaa Morsi and Constable Connor Jaksa were working together in a car from Auburn Police Station. They acknowledged the police computer entry and attended Mr Syed Ahamed’s address at 1.35pm.
Mr Syed Ahamed was not there, but after making a number of enquiries Constable Morsi managed to get in touch with him on his mobile phone. They arranged that he would speak with them at Auburn Police Station.
The interview with Auburn Police on 26 February 2023
Constables Morsi and Jaksa, which Constable Morsi recorded on her policeissue Body Worn camera.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
The recording of this conversation was played in court at the inquest. As noted by Counsel Assisting, interpretation of some things which Mr Syed Ahamed said is complicated by limitations in his English language skills.
In brief, Mr Syed Ahamed told the officers:
° his older brother had a friend living in Auburn who was ‘oppressing him’.
He was worried about what this person might do: ‘You know if | do something, they spread the news, maybe they will attack me or attack my family in India, my family, my mother, my sister’.
° he didn’t want to live in India because ‘foo much trauma, too much torture in India ... | live safe here and also | want to live like normal people, like Australian people ... | want freedom. | want peaceful so that’s why | love this country’.
° he was suffering what he described as ‘trauma’: ‘I’m too much problem because you over torture before, before even | was in India over torture, over push work. And also trauma from, from my seven years’ work, until I'm trauma ... Trauma means my family problem, my family issues, too much trauma’.
Mr Syed Ahamed also told the police officers that he was being pressured to work with his brother in a supermarket business in India. He asked the officers if he could move to another city in Australia, to which Constable Morsi replied that he could move anywhere he wanted, subject to the terms of his bridging visa.
When Constable Morsi asked Mr Syed Ahamed if he suffered any mental health problems, he told her he was seeing Dr Hameed and had been taking medication since 2013, but was now taking less because he had ‘become very good’. He also assured Constable Morsi that he had never attempted to take his own life or tried to hurt himself.
Constable Morsi asked Mr Syed Ahamed how he was feeling at that moment.
He replied:
‘I feel calm. | feel calm, but sleeping very less. Because [ don’t have money at the moment. God, but | believe that God will give everything. Beautiful wife, house, my future will be better. | wilf make more money, billions of dollars inshallah’.
After Constable Morsi turned off her Body Worn camera, Constable Jaksa asked Mr Syed Ahamed what he wished the police to do. Mr Syed Ahamed asked if they could speak to his brother's friend and tell him to stop contacting him.
Constable Morsi said they couldn’t do that, but that Mr Syed Ahamed could remove that person from all his communications platforms. He seemed content with this suggestion.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
44,
Constable Jaksa then asked Mr Syed Ahamed if he ‘heard voices’. He replied that he could hear Constable Jaksa’s voice.
Before Mr Syed Ahamed left, the two officers discussed whether they needed to pursue any mental health pathways for him. They thought that they did not, but they consulted their supervisor Sergeant Nathan Atfield, who agreed with their assessment.
At the inquest, both officers explained why they did not consider that Mr Syed Ahamed met the threshold under the Mental Health Act 2009 to be taken to a mental health facility, or otherwise needed mental health interventions.
Constable Morsi said that she had had observed that Mr Syed Ahamed was able to understand and answer her questions. Nothing that he said had caused her to think that he needed a mental health assessment. He did not appear to be suffering any loss of reality: when he spoke of being ‘oppressed’ he had explained that he meant he was feeling pressure and stress, and that he felt that his brother and his brother's friend were trying to force him back to India against his will.
The officers, in particular Constable Morsi, also took into account the likelinood that Mr Syed Ahamed used words differently to the way in which a native English speaker might. Thus they did not consider that his words necessarily reflected persecutory delusions, but were rather his attempts to describe his distress as a result of the family pressure upon him to return to India on a permanent basis, and to marry a person without the opportunity of seeing a photo of her beforehand. It was within this context that they interpreted his use of the terms ‘mental torture’ and ‘trauma’.
Furthermore, Mr Syed Ahamed had denied any previous attempts to take his own life, and had told the officers that his doctor was treating him with medication.
Constabie Morsi noted in addition that Mr Syed Ahamad appeared to be an observant Muslim, and being of that religion herself, she was aware that it was against their faith to commit suicide.
In summary, Constables Morsi and Jaksa did not consider that Mr Syed Anamad required mental health intervention. The appropriateness of this decision is discussed later in these findings.
The evening of 27 February 2023
At approximately 11.00pm on the following night, Mr Syed Ahamed’s room mate Mr Arslan Ahmad came into their shared bedroom and observed him to be talking on the phone. He heard Mr Syed Ahamed calling the person to whom he was speaking ‘Ma’. Mr Ahmad surmised this was Mr Syed Ahamed’s mother, but as they were speaking in the Tamil language he did not know what was being said.
However Mr Ahmad told police that during this call Mr Syed Ahamed was distressed and crying, and was pacing around the room.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
After Mr Syed Ahamed’s death, with the assistance of an interpreter the investigating police asked his family members about this last phone call.
According to Mr Syed Ahamed’s mother, her son was simply enquiring about the family and whether anyone needed money: ‘He seemed happy. Like normal. He didn't cry and just enquired about the family’.
Mr Syed Ahamed’s sister Masootha was apparently present with her mother for part of the phone conversation. She initially told police that her brother had seemed happy, but when she was asked if he had seemed upset, she replied that there were delays in getting his visa and that this did appear to have upset him.
When the phone call ended Mr Ahmad observed Mr Syed Ahamed to leave the bedroom and then return. He took off the traditional Tamil robe which he usually wore to bed, and changed into black pants. When Mr Ahmad asked him where he was going, he did not reply. According to Mr Ahmad, it was not normal for Mr Syed Ahamed to ignore him like that. He added that Mr Syed Ahamed had an angry look on his face.
Mr Syed Ahamed then left the room. The evidence establishes that he walked to Auburn Railway Station, arriving there at around 12.02am.
At Auburn Railway Station
53,
54,
55,
CCTV footage shows Mr Syed Ahamed arriving at Auburn Railway Station and walking through the concourse area to the ticket barriers. He remained standing there for two minutes.
At this time Mr Aaron Dole, a Sydney Trains cleaner, was approaching the other side of the ticket barriers. Mr Syed Anhamed walked through one of the barriers and advanced on Mr Dole, saying the words ‘Sorry man’. Holding a knife in his right hand he lunged towards Mr Dole’s chest area. Mr Dole threw up his left arm and in doing so, received a slash injury to that arm.
Stumbling backwards, Mr Dole fell to the ground. Mr Syed Ahamed again advanced on him, swinging the knife with force towards his chest. Mr Dole lashed out with his legs, and was stabbed to his right upper thigh. He managed to get up and run away, calling out for help as he ran.
Mr Syed Ahamed turned and ran back through the ticket barrier, across the concourse, and out onto the street.
Meanwhile Sydney Train employees ran to Mr Dole’s aid, calling for an ambulance and police. An ambulance crew took Mr Dole to hospital where he underwent surgery for his stab wounds. He was able to be discharged later that afternoon.
Notably, Mr Syed Ahamed was completely unknown to Mr Dole, and he has no idea why he was attacked.
Findings in the inquest into the death of Mohamed Rahmathullah Syed Ahamed
At Auburn Police Station
Still carrying the knife Mr Syed Ahamed ran towards Auburn Police Station, arriving outside its street entrance at 12.06am. CCTV footage shows that he remained outside the building for just over a minute.
Auburn Police Station is located in the Auburn Council building. The street entrance has automatic glass sliding doors which open into a shared foyer. On the left side of this foyer there is a second set of glass sliding doors, which leads into the foyer of Auburn Police Station. This has a counter area which is separated from the public by perspex. To its side, two secure coors give police officers access into the police station.
The stabbing of Mr Dole had just been broadcast over police radio. Constable (now Senior Constable) Joshua Hotham and Constable Sheimaa Morsi were both on shift at Auburn Police Station. They acknowledged the job and made their way out of the police station’s secure area, through the police station foyer, and out into the shared foyer. They intended to walk to their nearby police car, and drive to Auburn Railway Station to investigate.
As the two police officers passed through the shared foyer towards the glass sliding doors, Mr Syed Ahamed immediately entered the same foyer from the street. He walked towards the two officers, holding the knife in his right hand.
in their evidence, both officers said that although Mr Syed Ahamed had his right arm by his side, at all times he held the knife with its blade pointed not downwards at the ground, but outwards towards them. Their evidence as to the position in which the knife was held is confirmed by the CCTV footage.
Constable Morsi immediately recognised Mr Syed Ahamed as the man she had spoken with at the police station the previous afternoon. This time however he looked ‘completely different’, as though he was ‘not there’. She did not have time to tell Senior Constable Hotham this. For his part, Senior Constable Hotham did not connect the man now walking towards him, with the stabbing incident to which he and Constable Morsi were responding.
According to Senior Constable Hotham, as soon as his eyes met those of Mr Syed Ahamed, Mr Syed Ahamed started walking towards him. Senior Constable Hotham called out to him, directing him to get on the ground.
Mr Syed Ahamed did not get on the ground, but continued to advance towards the two officers. Both officers began to move backwards, through the shared foyer and then through the doors and into the police station foyer. As they did so, Senior Constable Hotham took his service pistol from its holster and using both hands, pointed it towards Mr Syed Ahamed. He again directed Mr Syed Ahamed to get on the ground.
Observing Senior Constable Hotham to draw his firearm, Constable Morsi drew
her Conducted Electrical Weapon (Taser) from her appointments vest. In her evidence she agreed that her Taser would not have been an appropriate choice
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
as a first response, as it may not have been successful in immobilising Mr Syed Ahamed. Her intention, she said, was to have the Taser as a back up option in the event that Mr Syed Ahamed complied with Senior Constable Hotham’s direction.
When Mr Syed Ahamed reached the police station foyer and was within 3-5 metres of the two officers, Senior Constable Hotham discharged three rounds from his service pistol. In accordance with police training, he aimed for Mr Syed Ahamed'’s chest. Mr Syed Ahamed fell face down to the ground, at about the mid point of the police station foyer.
It was now 12.08.11am, just thirteen seconds after the two officers had exited the police station secure doors.
Other police officers immediately came to the scene. One officer removed the knife from Mr Syed Ahamed’s right hand, after which he was placed in the recovery position. He was still breathing, but with difficulty. First aid efforts commenced, with chest compressions and attempts to stem the bleeding. These efforts continued unti! NSW Ambulance paramedics arrived at 12.16am. Mr Syed Ahamed was by now unconscious and had ceased breathing.
At 12.25am an Intensive Care Paramedic Team arrived, followed by an Ambulance Medical Team. These clinicians carried out advanced lifesaving interventions, including a ‘clamshell thoracotomy’.
Mr Syed Ahamed was taken to Westmead Hospital by ambulance, with treatment continuing on the way. Shortly after arrival there however, he was pronounced deceased.
The post mortem examination
An autopsy was conducted on 2 March 2023 by trainee forensic pathologist Dr Lena Quinto, under the supervision of Senior Staff Specialist Forensic Pathologist Dr Issabella Brouwer. The pathologists gave the cause of Mr Ahamed’s death as ‘gunshot wounds to the chest and upper arm’.
Toxicological analysis of Mr Syed Ahamed’s blood revealed only a therapeutic concentration of paracetamol. No trace of Mr Syed Ahamed’s prescribed medication Risperidone was detected.
However at the inquest, expert pharmacologist Dr Pieternal Sonia Van Nieuwenhuijzen commented that Mr Syed Anamed was on a very low dose of Risperidone, being a 0.5mg dose two days per week. Had he been taking this medication as prescribed, the level in his blood would be below that which can be detected. Thus it cannot be concluded from the toxicological evidence that Mr Syed Ahamed was not taking this medication at the time of his death.
Further testing of Mr Syed Ahamed’s blood identified the presence of his other prescribed medication oxcarbazepine, and its metabolite licarbazepine.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
| conciude that the cause of Mr Syed Ahamed’s death is gunshot wounds to the chest and upper arm.
| now address the issues examined in the inquest.
Was Mr Ahamed suffering from an identifiable mental illness or mental health condition at the time of his death? If so, did it affect his behaviour immediately prior to his death?
The court heard evidence on this issue from Mr Syed Ahamed’s treating doctor, Dr Asian Hameed, and from forensic psychiatrist Dr Kerri Eagle. Dr Eagle had been asked to review the material and provide her expert opinion as to what Mr Syed Ahamed’s mental state was likely to have been at the time of his death, and in the days leading up to it.
The evidence of Dr Hameed
Before coming to Australia, Mr Syed Ahamed had consulted with a psychiatrist (known only at the inquest as Dr Balan), who prescribed him with two medications. These were Risperidone which is an antipsychotic medication, and the mood stabiliser oxcarbazepine.
In Australia Mr Syed Ahamed regularly attended a general practitioner, Dr Aslam Hameed. Mr Syed Ahamed had appointments with Dr Hameed on a regular basis, commencing with their initial one on 11 April 2020. Their consultations were conducted in the Tamil language, in which Dr Hameed was fluent.
It appears that Mr Syed Ahamed was not aware what his mental health diagnosis was. But at their consultation on 11 April 2020, he showed Dr Hameed a document on his phone which listed the two medications which Dr Balan had prescribed for him. This document noted a diagnosis of bipolar disorder.
Mr Syed Ahamed toid Dr Hameed that he had been using the two medications for three years. He did not mention to Dr Hameed anything about having psychotic episodes, only that he had problems with sleep.
Throughout the period of his treatment of Mr Syed Ahamed, Dr Hameed considered that he was stable. Mr Syed Anamed never reported any signs of psychosis or delusion, and nothing about his behaviour indicated that he was not complying with his medication regime.
In their consultations Mr Syed Ahamed told Dr Hameed quite a lot about his personal circumstances. According to Dr Hameed, at each consultation Mr Syed Ahamed spoke of the difficulties and arguments that he was having with his family in India. ‘t was clear to Dr Hameed that Mr Syed Ahamed wanted to remarry, to earn money and, as Mr Syed Ahamed put it, ‘fo five freely like an Australian’. He told Dr Hameed that his family was trying to force him back to India to live there permanently, but that he did not like this idea. Dr Hameed assessed that family pressure was a major stressor in Mr Syed Anamed's life.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Anamed
Considering that Mr Syed Ahamed's condition was relatively stable, in February 2022 Dr Hameed commenced reducing his dosage of Risperidone. Mr Syed Ahamed had reported that this medication was making him drowsy and was reducing his concentration at work. Dr Hameed therefore began a gradual reduction, with reviews every two to four weeks. By the time of his death, Mr Syed Ahamed’s dosage of Risperidone was down to 0.5mg two times per week.
At the inquest Dr Hameed was asked if he had considered referring Mr Syed Ahamed to a psychiatrist for advice, before making this decision. Dr Hameed replied that Mr Syed Ahamed had no private health insurance, which would make a psychiatric review expensive for him. In addition, he considered that his mental condition was stable.
Dr Hameed did not however reduce Mr Syed Ahamed’s dosage of oxcarbazepine. In his opinion, this medication was appropriate for patients with long term bipolar disorders, and it would be necessary to obtain the opinion of a psychiatrist before altering its dosage.
The evidence of Dr Eagle
In her expert report and evidence, Dr Eagle acknowledged that she had never met Mr Syed Ahamed, and that this limited her ability to be definitive about what his mental condition was. A further challenge was the absence of clinical information from his psychiatrist in India.
Having reviewed the material, Dr Eagle’s view was that in the period leading up to his death Mr Syed Ahamed was suffering a depressive episode with psychotic features. He was, in her opinion, likely experiencing a relapse of psychotic symptoms in the context of bipolar disorder or a chronic psychotic disorder.
in support of this conclusion, Dr Eagle cited evidence of strange and erratic behaviour on Mr Syed Ahamed’s part during this last period. This included his expressed belief that his brother would travel to Australia to take him back to India and kill him; his attendance on police on 26 February 2023 with descriptions of ‘mental torture’, and his extraordinary and shocking act of violence against Mr Dole.
As to what might have contributed to Mr Syed Ahamed's relapse, Dr Eagle noted that around the time of his death he appeared to be experiencing increased stress. This of itself may have made him vulnerable to relapse. It also coincided with a reduction in his dosage of Risperidone. This, she commented, was unfortunate timing, but not something for which Dr Hameed could be considered responsible, given that there was a clinical basis for him to have instituted the dosage reduction, and the caution with which he carried this out.
Dr Eagle was also asked to review Mr Syed Ahamed’s interview with the two police officers on 26 February 2023, and to offer her opinion as to what it indicated about Mr Syed Ahamed’s mental condition at that time.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
Dr Eagle expressed the view that in this interview it was reasonably apparent that Mr Syed Ahamed was displaying delusions and persecutory beliefs. Her conclusion was in part based on his references to suffering ‘mental torture’ and oppression. It was clear to her, she said, that he required a qualified mental health assessment and that it would have been reasonable’ for the police officers to have sought this for him.
Ata later point in these findings | will consider whether the decisions made by Officers Jaksa and Morsi on 26 February 2023 were reasonable.
Conclusion
1 accept the evidence of Dr Eagle that at the time of his death Mr Syed Ahamed was experiencing a relapse of psychotic symptoms, in the context of bipolar disorder or a chronic psychotic disorder. | accept her further evidence that it is very probable this relapse was seriously affecting his behaviour in the period leading up to his death.
Itis convenient to consider at this point whether Dr Hameed's care and treatment of Mr Syed Ahamed was adequate and appropriate, in particular his decision to reduce his Risperidone and to have done so without the advice of a specialist psychiatrist.
Dr Eagle’s opinion was sought on these questions. In her view it was reasonable for Dr Hameed to have decided to reduce Mr Syed Ahamed’s dosage of Risperidone, given his mental stability and the adverse side effects of which he was complaining. In her opinion, the reduction process was carried out in a cautious and entirely appropriate manner.
Nor was Dr Eagle critical that Dr Hameed had not referred Mr Syed Ahamed for a psychiatric review to guide his decision to reduce his Risperidone dosage. She agreed that a private psychiatric review would be expensive. And had Mr Syed Ahamed sought such a review within the public health system, his case was unlikely to have been prioritised and there would probably have been a long delay before he received an appointment.
| therefore conclude that the treatment which Dr Hameed provided to Mr Syed Ahamed was entirely appropriate, and was in accordance with acceptable clinical standards.
! now turn to the next issue for examination, which focuses upon the interaction between Officers Jaksa and Morsi with Mr Syed Ahamed on 26 February 2023.
Did the police officers interact appropriately with Mr Ahamed on 25 and 26 February 2023?
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
102.1 accept the submission of Counsel Assisting, and of Counsel for the Commissioner, that police took adequate and appropriate steps to try to locate Mr Syed Ahamed in response to his 000 call.
As regards the police officers’ interactions with Mr Syed Ahamed on 26 February 2023, | have detailed above the evidence regarding this, including the footage captured on Constable Morsi's camera.
Dr Eagle was asked to review this evidence, and to provide her opinion as to whether the officers’ decisions regarding Mr Syed Ahamed's mental health that afternoon were appropriate. In her expert report Dr Eagle opined that on the basis of how Mr Syed Ahamed was presenting, it would have been reasonable for the two police officers to have tried to obtain a mental health assessment of him.
tn her oral evidence however Dr Eagle acknowledged that police officers are not mental health professionals, and further that Mr Syed Ahamed had not presented fo them as a person at risk of harming himself or others. Dr Eagle agreed that in these circumstances it was not unreasonable for the officers to have decided that the threshold for them to take action under section 22 of the Mental Health Act 2007 had not been met. This section empowers police officers to take a person to a mental health facility, if it appears to them probable that the person will attempt to kill or cause serious harm to themselves or to other persons.
As to whether the officers ought to have sought alternative means of having Mr Syed Ahamed mentally assessed, Dr Eagle readily conceded that he had told the officers that he felt calm, and that he was under the care of a doctor who prescribed him medication for his mental health. She acknowledged further that both officers had listened carefully to Mr Syed Ahamed, and had responded to him with in respectful manner. Furthermore they had taken the precaution of checking their assessment of the situation a more senior officer.
In these circumstances Dr Eagle stated that it was ‘nof unreasonable’ for the officers not to have taken any further steps to obtain a mental health assessment of Mr Syed Ahamed. She added however that if such any such options had been available to them, it would have been ‘prudent’ for them to have explored these.
On this issue, the court heard evidence from Acting Superintendent Kirsty Hales, who is the Acting Commander of the NSW Police Force's Mental Health Command Capability Performance and Youth Command. Acting Superintendent Hales is also a registered forensic psychologist.
The evidence of Acting Superintendent Kirsty Hales
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Anamed
The availability of alternative options for Mr Syed Ahamed to receive a mental health assessment on 26 February 2023.
As regards the first issue, Acting Superintendent Hales stated that the response of the two officers was consistent with their training and with NSW Police Force policy. The officers had questioned Mr Syed Ahamed carefully, and in her opinion, they had reasonably formed the opinion that his presentation did not meet the threshold for them to exercise section 22 of the Mental Health Act 2007.
Regarding issue two, Acting Superintendent Hales thought it was not unreasonable for the officers not to have chosen to seek alternate means of intervention. In her opinion and experience, the options for obtaining a mental health assessment were limited, even had the officers considered this was necessary. In short:
° the PACER service was not available at the Auburn Command at the time (this remains the case). The PACER program enables mental health clinicians to attend with police when they are responding to mental health emergencies.
e making contact with the local community Acute Care Team, to request a mental health assessment of Mr Syed Ahamed was unlikely to have resulted in an immediate attendance of Acute Care Team members at the police station, given the demands on their service.
Acting Superintendent Hales agreed that the two officers had the option of requesting that a paramedic team from NSW Ambulance attend to assess Mr Syed Ahamed. In her experience a paramedic team was generally available to attend the Auburn police station within an hour of contact.
However, in her further opinion it was not unreasonable for the officers not to have taken this step. They had drawn reassurance from Mr Syed Ahamed’s information that he was under the care of a regular GP for his mental health, was apparently using his medication as prescribed, had stated that he felt calm, and had not expressed any intentions of harming himself or anyone else.
Conclusion
In closing submissions, Counsel Assisting stated that on the basis of the evidence, it would be open for the court to conclude that the decisions made by Officers Jaksa and Morsi that afternoon were reasonable and appropriate, and were consistent with NSW Police policy and training.
| accept this submission. It is apparent that Constables Jaksa and Morsi turned their minds to the question of whether Mr Syed Ahamed’s presentation required them to seek a mental health assessment of him that afternoon. Their assessment that he did not meet the threshold required under section 22 of the Mental Health Act 2007 was reasonable.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
As to whether they ought to have taken other steps to have him mentally assessed, | take into account both the limited options that were available to them, and the information they had about him which is set out in paragraphs [31]-[45] above.
For these reasons, | find that the decisions made by the two police officers on 26 February 2023, and their interaction with Mr Syed Ahamed, were reasonable and were in accordance with NSW Police policy and training.
Were the actions of the police officers on 28 February 2023 appropriate, in particular the decision of Senior Constable Hotham to use lethal force?
| have described above the chain of events which commenced shortly after midnight on 28 February 2023, and which culminated in the tragic shooting of Mr Syed Ahamed. The evidence given by Senior Constable Hotham and Constable Morsi about these events is summarised below.
By way of background, at the inquest the court heard evidence from Sergeant Matthew Genders, who is a senior training officer within NSW Police Force’s Operational Safety Training and Governance. He had provided an expert statement concerning policy and training in the appropriate use of force by NSW police officers.
in short, NSW police officers are trained that they should only use force which is reasonable, necessary and proportionate to the situation they face. The Tactical Options framework teaches officers that the use of force is based upon their assessment of the level of resistance they meet, weighed against the level of force or response required to control the situation.
Sergeant Genders’ evidence was that use of lethal force will be justified if an officer assesses that they or another person will be killed or seriously injured, and that there is no other way to stop the threat.
Furthermore, if officers determine that use of lethal force is required, they are trained to aim at the person’s centre of mass rather than at their limbs or pelvis.
This is due to the chance of missed shots, risking the result that the person is not stopped and that innocent bystanders are instead hit.
The evidence of Senior Constable Hotham and Constable Morsi
Senior Constable Hotham’s evidence about the confrontation with Mr Syed Ahamed that night may be summarised as follows:
. Mr Syed Ahamed started walking towards him the instant he saw him. His expression was angry and he had a clenched jaw, and his expression did not change throughout the interaction
. as soon as he saw Mr Syed Ahamed’s knife Senior Constable Hotham pulled out his firearm, told Mr Syed Ahamed to get on the ground, and started walking backwards
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
. he had tried to keep a safe distance between himself and Mr Syed Ahamed, but Mr Syed Ahamed was moving towards him at a pace that was closing the gap, until there was no further space for himself or Constable Morsi to retreat to
° when Mr Syed Ahamed was within about three metres of himself, he felt sure that if he did not discharge his firearm, Mr Syed Ahamed would use his knife to stab himself or Constable Morsi. He based this belief on Mr Syed Ahamed’s angry expression, that he had refused to get on the ground even though a firearm was being pointed at him, and the manner in which he was holding the knife, that is with its blade pointed outwards towards himself and Constable Morsi.
Senior Constable Hotham told the court that he discharged his firearm at the point where Mr Syed Ahamed had advanced through the police station sliding doors and had entered the police station foyer, at an estimated three metres from himself and Constable Morsi.
Senior Constable Hotham was asked if he had considered using any alternatives to lethal force. He replied that he had, but that none were appropriate to the nature of the threat. OC spray or Taser could not be relied on to stop Mr Syed Ahamed’s advance in time to avoid being stabbed. Use of baton risked serious injury to himself due to the need to get up close to Mr Syed Ahamed in order to deploy it.
in her evidence Constable Morsi agreed that she and Senior Constable Hotham had retreated almost as far as the poiice station counter, and had no further space to keep a distance between themselves and Mr Syed Ahamed. She was likewise of the opinion that Mr Syed Ahamed intended to kill or seriously injure one or both of them.
Conclusion
The evidence supports the conclusion that it was reasonable in all the circumstances for Senior Constable Hotham to have discharged his firearm at Mr Syed Ahamed, and that his action in doing so was consistent with NSW Police Force policy and training. The evidence supports a finding that the officers’ assessment that they faced serious injury or death was well founded, and justified the use of lethal force.
Both officers were impressive witnesses who gave their evidence in a straightforward manner. Furthermore their evidence was corroborated in important ways by the CCTV footage which was tendered at the inquest and played in court. The CCTV evidence corroborates that of the officers, that they attempted to create space between themselves and Mr Syed Ahamed, but quickly reached a point where no further space was available to them. The CCTV footage likewise corroborates the evidence of Senior Constable Hotham that when he discharged his firearm, Mr Syed Ahamed was within three to four metres of him and was continuing to advance with the knife in his hand.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
The question of recommendations
The evidence does not disclose the need for any recommendations, in the interests of public health and safety.
However in closing | wish to mention an internal review recently undertaken by the NSW Police Force regarding their response to mental health incidents in the community. A Summary of the review’s findings was tendered at the inquest, and in her evidence Acting Superintendent Kirsty Hales adverted to this document.
The review noted that in NSW there has been an increased dependence on police as the first responders to people who are suffering severe emotional distress or mental health crisis. It acknowledged that a police response will always be required where there is a threat to public safety. Where this is not the case however, the review identified a need for NSW Police Force to work with NSW Health to explore a health-led rather than a police-led approach to such incidents.
As acknowledged in the review, since police are not mental health professionals they are in many cases not best placed to respond to such incidents. Their attendance can escalate the situation and unintentionally cause harm.
In short, the review concluded that police attendance at many mental healthrelated incidents does not address the needs and risks of people experiencing severe emotional or mental distress; and places an increasing demand upon police services. It recommended that a more health-based model of response be explored, with further consultation with NSW Health, NSW Ambulance and those who provide and receive mental health services.
In the case of Mr Syed Ahamed, Acting Superintendent Hales was asked if the response to his requests for help might have been different, had a health-led model been in operation in February 2023.
Acting Superintendent Hales replied that in all likelihood the 000 call which Mr Syed Ahamed made on 25 February 2023 would have been triaged not to police, but to a health service. She commented that the content of this call did not disclose an imminent threat of harm to himself or to anyone else, or the presence of weapons. On this basis it was likely his call would have been triaged to NSW Ambulance, in order for Mr Syed Ahamed to receive a mental health assessment by a team of paramedics.
The consultative work which is being undertaken into this alternative model is of great interest to those of us who work in the coronial area, and we look forward to learning more about it in due course.
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahamed
Conclusion
On behalf of the Coroners Court, | offer my sincere sympathy to Mr Syed Ahamed’s family for the tragic loss of their son and brother.
| thank the Assisting team for their substantial support and assistance, and the Officer in Charge of the coronial investigation, Detective Sergeant Scott Jamieson and the previous Officer in Charge, Detective Chief Inspector Paul Smith.
Findings
Identity The person who died is Mohamed Rahmathullah Syed Ahamed
Date of death: Mohamed Rahmathullah Syed Ahamed died on 28 February 2023
Place of death: Mohamed Rahmathullah Syed Ahamed died at Westmead Hospital, Westmead
Cause of death
Mohamed Rahmathullah Syed Ahamed died as a result of gunshot wounds to his chest and upper arm.
Manner of death:
Mohamed Rahmathullah Syed Ahamed’s death occurred as a result of a police operation.
| close this inquest.
& y
Magistrate E Ryan Deputy State Coroner
Lidcombe
5 February 2025
Findings in the Inquest into the death of Mohamed Rahmathullah Syed Ahnamed
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