Dhu was allocated an Australian triage scale score of four, which meant she needed to be seen within 60 minutes. She was not seen by Naderi, however, for another two hours. The doctor performed an ultrasound and in his notes stated Dhu was a “difficult patient to assess” and recorded “withdrawal from drugs” and “behavioural issues”. He prescribed a psychoactive drug and painkillers, before signing a form that declared her fit for custody. Less than one day later, she was dead. Dhu was taken back to the hospital on 4 August. She was unconscious, without a pulse and not breathing on arrival. Resuscitation was attempted but she died shortly afterwards.