Finding into death of Ali Sultan Zaidi

FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 . Court reference: 3771/07

Inquest into the Death of ALI SULTAN ZAIDI

Delivered On: 19 May 2010

Delivered At: 436 Lonsdale Street, Melbourne 3000 Hearing Dates: 19 May 2010

Findings of: JOHN OLLE

Representation: N/A

Place of death: Ormond Road, Moonee Ponds, Victoria 3039

SCAU: - Leading Senior Constable Tracey Ramsey

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008

Court reference: 3771/07 In the Coroners Court of Victoria at Melbourne I, JOHN OLLE, Coroner having investigated the death of: Details of deceased:

Sumame: ZAIDI

First name: ALI

Address: 2 Muirhead Gardens, Caroline Springs 3023 AND having held an inquest in relation to this death on 19 May 2010 at Melbourne find that the identity of the deceased was ALI SULTAN ZAIDI and death occurred on 24th September, 2007 ° ,

at Ormond Road, Moonee Ponds, Victoria 3039

from la. HEAD AND CHEST INJURIES SUSTAINED IN A FALL FROM A HEIGHT

in the following circumstances: |

1, Al Zaidi was aged 30 years at the’ time of his death. He lived at 2 Muirhead Gardens, Caroline Springs.

2. Detective Senior Constable Kayne Josephs has prepared a comprehensive coronial brief. A summary prepared by him has provided particular assistance. 1 note the following ‘pertinent factors:

¢ At approximately 9.00am on the 24th September, 2007, Mr Zaidi was at home with his brother-in-law, Mr Kabir.

e Mr Zaidi commenced to display unusually aggressive behaviour which caused his brother-inlaw to call police.

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¢ Police attended at which time Mr Zaidi’s threatening behaviour had abated. Following a telephone discussion with Mrs Kabir (Mr Zaidi’s sister), Mr Zaidi agreed to travel with police to meet Mrs Kabir at Caroline Springs Police Station,

¢ Police offered to transport Mr Zaidi to a local hospital. Mrs Kabir expressed a preference lo transport him to the Royal Melbourne Hospital and arranged to meet Mr Zaidi at Caroline Springs police station. |

© Mr Zaidi-had prior admissions at Royal Melbourne Hospital.

• Mr Zaidi agreed to police transport to meet his sister at the police station.

e He sat in the foyer awaiting Mrs Kabir’s arrival, He was calm throughout and at no stage exhibited the aggressive behaviour, witnessed earlier by Mr Kabir.

e Upon her arrival, Mr Zaidi agreed to accompany Mrs Kabir to hospital. They calmly left the police station, holding hands. : .

3. Mr Zaidi had never previously exhibited aggressive conduct. In light of his calm demeanour, it was appropriate he accompany Mrs Kabir to hospital.

4, There was no reasonable basis to anticipate Mrs Kabir would have any difficulty transporting Mr Zaidi to hospital.

5. The police were not dismissive of Mr Zaidi’s welfare. At all times, trealing him with respect and appropriately communicating with his family.

Without warning, Mr Zaidi exhibited manic behaviour

6. En route to the Royal Melbourne Hospital,-it appears that Mr Zaidi suffered a manic episode, He made the impulsive, unforeseeable decision to alight from the motor vehicle and abscond.

Events subsequent to Mr Zaidi’s absconding from Mrs Kabir’s car

7. From the moment he absconded until his tragic death, Mr Zaidi exhibited bizarre behaviour, reflective of suffering a psychotic episode. ‘

8. Mrs Kabir immediately notified police.

9. L.am satisfied that the endeavours of police to locate Mr Zaidi were appropriate. As the time passed, and police unable to locate Mr Zaidi, Mrs Kabir’s distress heightened.

10, Tragically, Mr Zaidi was observed by police moments before his death.

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11. 1 am satisfied that Mr Zaidi’s death occurred in circumstances in which he was acutely psychotic. The decision to jump to his death was made in response to psychotic symptoms he was then suffering. The decision to jump was not related to the conduct of police, or any other person.

12. Indeed, Mr Zaidi had previously stated he could jump from a bridge without suffering injury.

Psychiatric Assessment conducted on 20 September, 2007

13. Mr Zaidi was under the care and treatment of Dr Ashok Mishra, Psychiatrist.

14. On 20th September, 2007, Mr Zaidi arranged an urgent appointment with Dr Mishra complaining of racing thoughts, paranoid thinking and difficulty in sleeping. In his report to the coroner, dated 18th August, 2009, Dr Mishra explained:

"| started treating Mr Zaidi for his Bipolar Affective Disorder on 22 March 2007.... Mr history of episodes involving Bipolar Affective Disorder starting at least in 1994 when he was living in India. He stated that he had at least 4 manic episodes. and there were times of depression and suicidal behaviour. He migrated to Australia in 2006. I treated hin for approximately 6 months until his death in September 2007. The visits were rather sporadic, For the most part he was treated with Lithium and Risperidone."!

15. Mr Zaidi attended with his sister on the 20th September 2007, complaining of racing

thoughts and paranoid thinking. Dr Mishra noted he was taking Lithium 500mg twice a day and Risperidone 2mg at night. He also had some Temazepam for sleep.

"I gave him Olanzapine Smg at night and asked him to continue with his other medications.”

16. Dr Mishra was concerned about medication compliance however, stated:

"He certainly did not express any thoughts of suicide to me just prior to his death."*

17, I find no basis to’ criticise the management by Dr Mishra. Further, there is no basis to Suggest Mr Zaidi’s specific plan was to commit suicide which would have warranted more stringent intervention orders on the part of Dr Mishra,

! Statement of Dr Mishra dated 18 August 2009.

2 Statement of Dr Mishra dated 18 August 2009.

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18. Mrs Kabir explained that in the days following his appointment with Dr Mishra, her brother seemed fine and "just potted around the house for a few days.”

19. It is apparent that Mr Zaidi’s sister was extremely loving and supportive of him. Further, she had excellent knowledgé of his diagnosis. :

20, In documents held by Dr Mishra, he noted a conversation with Mrs Kabir on 31st October,

2007, in which she expressed a belief that her brother’s death was:

"a panic reaction, he was not suicidal - he never meant to hurt himself."3

21. On the basis of all material obtained from the course of my investigation, I am satisfied that Mr Zaidi’s death was the result of an impulsive and unforeseen act committed in response to

psychotic symptoms being suffered by him.

22. It follows there was no reasonable prospect of the effect of intervention by either his mental health professionals, police and/or family.

In Summary

23, Mr Zaidi was appropriately taken for psychiatric review on the 20th September, 2007. Dr Mishra conducted a mental state assessment and reviewed his medication regime. He did not consider Mr Zaidi suicidal. Further, Mr Zaidi did not express suicidal ideation.

24. According to Mrs Kabir, in the days prior to his death, her brother was fine.

25. At no stage between the psychiatric consultation on 20th September and the event leading to his absconding from Mrs Kabir’s car, did his behaviour warrant attention pursuant to the Mental

Health Act 1986.

26. The onset of psychosis and subsequent death of Mr Zaidi was a tragic event which could not have been reasonably foreseen.

27. The medical records of the Royal Melbourne Hospital, February 2007, Mr Zaidi expressed the delusional belief that:

"people can jump off buildings and Jesus will catch them."4

3 Dr Ashok Mishra.

4 1B RMH Medical Notes p.383

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28. It cannot be known whether the decision to jump, which tragically resulted in his death, was made in the delusional belief that he not come to harm.

29, Whether or not he held the belief, I am satisfied that due to the psychotic symptoms he was suffering at the time of his death, he could not form the necessary intent to commit suicide.

30. No person, other than Mr Zaidi, was responsible for his death, Due to psychotic symptoms suffered by him, I do not find that he committed suicide.

Post Mortem Medical Examination

31. On 25th September, 2007, Dr Katherine White, Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed an autopsy.

32. Dr White found the cause of death to be head and chest injuries sustained in a fall from a height.

33, Dr White reviewed toxicological analysis post mortem and found Olanzapine consistent with therapeutic use. |

34, 1 find the cause of death of Ali Zaidi to be head and chest injuries sustained in a fall from a height ip ci\cumstances in which he did not commit suicide,

Jo.

Cojoner 19th M:

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