Agreed facts
On 3 August 2021, Ms Dhu was taken to an emergency department complaining of rib pain and shortness of breath while in police custody. At triage, she was found to have a rapid pulse, was dehydrated and was ‘warm’ and ‘agitated’. She was triaged to be seen within 60 minutes but was not seen by Dr Naderi until approximately two hours after triage.
Dr Naderi performed an ultrasound and noted that Ms Dhu was a ‘difficult patient to assess’ and recorded ‘withdrawal from drugs’ and ‘behavioural issues’. He prescribed benzodiazepine medication and analgesia before signing a form declaring that Ms Dhu fit for custody.
On 4 August, Ms Dhu was taken back to the hospital. She was unconscious, pulseless and not breathing. Resuscitation was attempted, but she died shortly afterwards. The cause of death was later established at inquest to have been staphylococcal septicaemia and pneumonia with osteomyelitis complicating a previous rib fracture.
Tribunal findings
Dr Naderi’s examination and investigation of Ms Dhu was inadequate and fell substantially below the standard of care expected of someone with his level of training and experience.
He failed to:
- read the triage nurse notations recording Ms Dhu’s heart rate and failed to appreciate the increase in Ms Dhu’s recorded heart rate from 2 to 3 August 2014;
- take Ms Dhu’s temperature in the presence of significant changes in her vital signs;
- order a chest x-ray;
- maintain adequate clinical records.
Dr Naderi also could have examined Ms Dhu in the area beyond the lower front ribs when she drew to his attention that the area was bruised and did not.
He discharged Ms Dhu into police custody and declared her fit to be held in police custody despite her tachycardia, and without signs, she was improving. He did not record his diagnosis or conclusions as to the explanation for her pain and did not advise her custodians as to the circumstances she should be returned to the emergency department.
It was taken into account in mitigation of penalty that Dr Naderi had taken full responsibility for his actions and remained deeply affected by the events of 3 August 2014. He was remorseful, had insight into his management and had taken steps to avoid a situation arising in similar circumstances.
Consent orders were made, including:
- a finding of professional misconduct;
- a reprimand;
- a fine of $30,000; and
- a condition to complete a reflective practice report.
The Tribunal orders can be read here.
