Coroner's Court of Western Australia

Inquest into the Death of Fazel CHEGENI NEJAD

Inquest into the Death of Fazel CHEGENI NEJAD

Delivered on :2 May 2019

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :Yes

Recommendation 1

I recommend that the Department/Commonwealth should work together with IHMS to make it a contractual requirement for IHMS to ensure that a psychiatrist is available to provide in-person psychiatric assessments at Christmas Island for detainees at least on a fortnightly basis, acknowledging the practicalities of limited flight services to the island.

Recommendation 2

I recommend that the Department/Commonwealth should work together with IHMS to make it a contractual requirement with IHMS that there be an increase in the number of mental health clinicians at Christmas Island than was the case at the time of Mr Chegeni Nejad’s death, so that there is a reduced delay between requests for medical attention and appointments. Clinical governance of the provision of mental health services by the mental health team should also be supervised by a psychiatrist.

Orders/Rules : N/A

Suppression Order : Yes

Suppression of the full name of the witness who will be referred to as “Katica” from publication. The suppression will include any evidence likely to lead to the witness’ identification.

Summary : The deceased at the time of his death was held at the North West Point Immigration Detention Centre on Christmas Island. The deceased did not have a valid visa to enter Australia and was detained in immigration detention in Australia as an “unlawful non-citizen” under the Migration Act 1958 (Cth).

The Coroner focused the scope of the inquest on the quality of the supervision, treatment and care of the deceased in the days prior to his death.

During the evening of 6 November 2015 the deceased escaped from the Christmas Island IDC by climbing an internal fence to access the roof of a building and then made his way over an external electrified permitter fence. The unauthorised exit triggered alarm sensors that sounded in the centre’s Control Room but the alarms were not interpreted correctly by the Control Room staff and the deceased’s escape initially went unnoticed.

A head count conducted a few hours later that evening identified that the deceased was missing from his allocated compound. As the fence alarms had not been understood by the Control Room staff to indicate a permitter fence breach, the search for the deceased was initially confined within the facility. It was believed the deceased might be hiding on a roof as he had been known to go onto the roof of other IDCs in the past. SERCO staff who ran the facility on behalf of the Commonwealth failed to locate the deceased and the matter was escalated to the AFP and ABF who became involved in the search the following morning. A review of the facility’s CCTV footage confirmed the deceased had approached the external permitter fence at about 9.15 pm the previous evening. An immediate search was conducted of the surrounding thick vegetation at the location where the deceased was last seen on the footage but he was not located.

A search resumed at 7.15 am on 8 November 2015. Two AFP officers discovered the body of the deceased approximately 50 metres from the facility’s perimeter fence line.

The Coroner heard evidence the deceased had spent a long time in the immigration detention system and over time, his prolonged detention had led to a deterioration in his mental health. Efforts were being made to release the deceased into the community, but the deceased remained in detention. He was transferred to Christmas Island IDC shortly before his death. The Coroner found the evidence suggested a detrimental affect on his mental health, as a result of the transfer, which could be causally connected to his death.

The Coroner concluded the mental health treatment by IHMS staff given to the deceased was attentive and generally of the same standard as would be provided in the community. The only difference was the constant movement of the deceased, which meant he had little continuity of care, and the absence of any regular in-person psychiatric review when he was at Christmas Island.

The Coroner made two recommendations relating to improving psychiatric services to detainees on Christmas Island.

Catch Words : Detention Centre : Mental Health Services : Psychiatric Services : Open Finding.


Last updated: 17-May-2019

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