Inquest into the death of Mohamad Ikraam Bahram
Deceased
Mohamad Ikraam Bahram
Demographics
24y, male
Date of death
2020-02-23
Finding date
2025-02-11
Cause of death
Multiple gunshot wounds
AI-generated summary
Mohamad Ikraam Bahram, a 24-year-old man with schizophrenia managed under a community treatment authority, died after being shot by police on Mary Street Brisbane following an unprovoked assault on a tourist. He had presented five days prior to a psychiatrist who saw no acute psychotic symptoms and continued assertive community management. Critical systemic issues identified: excessive psychiatrist caseloads (60+ patients) prevented meaningful therapeutic contact—communication occurred primarily through case managers rather than the treating psychiatrist. Risk assessment tools were completed via copy-paste function without clinical review, potentially missing deterioration signs. Medication management involved switching from depot to oral formulation in 2019, aligning with recovery principles but later re-started depot on 7 February 2020. The coroner found no single outcome-changing opportunity, but noted the operational environment was suboptimal. Key recommendations address caseload management, risk assessment value, advance health directives, and documentation systems—systemic factors rather than individual clinician error.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- schizophrenia with non-compliance with oral medication
- deterioration in mental state in days before death
- high psychiatrist caseloads limiting therapeutic contact
- risk assessment documentation deficiencies via copy-paste function
- lack of longitudinal perspective in risk assessments
- inadequate consultation between inpatient and community teams at discharge from December 2019 admission
- possible early signs of relapse missed by treating team
- family concerns about medication compliance not sufficiently acted upon
Coroner's recommendations
- Queensland Health to undertake a comprehensive project to review psychiatrist caseloads and appropriate staffing levels in community mental health services, consulting experienced clinicians and examining patient demographics and complexity to ensure caseloads support proactive (not reactive) care delivery and therapeutic relationships
- Metro South Health to implement case conferences at critical decision-making points (such as medication changes at discharge) involving inpatient and community teams, families, and consumers with a longitudinal perspective
- Queensland Health to develop statewide education initiative on advance health directives as a less restrictive treatment option for mental health consumers and healthcare staff
- Queensland Health to undertake a statewide project examining the clinical value of risk assessment screening tools and their frequency, considering whether time might be better spent on direct clinical contact rather than box-ticking KPI-driven documentation
- All Queensland Health CIMHA users to be reminded of the policy requiring clinical confirmation of the accuracy and relevance of information when using import or copy functions, and consideration of disabling copy-paste functionality to reduce carryover of outdated information
- Ensure adequate consultation between inpatient and community psychiatric teams regarding medication decisions, particularly regarding long-acting injectable antipsychotics, prior to discharge
- Police and Ambulance Intervention Plans (now Police Advice and Intervention Plans) to be developed for mental health consumers with prior police/ambulance involvement
- Queensland Health and Queensland Police to ensure consistent use of terminology (e.g., 'monitored patient') in information sharing to avoid confusion regarding level of monitoring
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