Coroner's Court of Western Australia

Inquest into the Death of Sarwan Hekmat Salman AL JHELIE

Inquest into the Death of Sarwan Hekmat Salman AL JHELIE

Delivered on : 15 July 2022

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : No

Orders/Rules : No

Suppression Order : Yes

Made on 20 October 2021: This order replaces the order previously made by the coroner on 19 October 2021. With the exception of the deceased, the name of any person mentioned in the proceedings, or any identifying details, either in open court, or in documents, files or tendering in the proceedings, who is or has been detained under the Migration Act 1958 (Cth) must not be published, in electronic form or otherwise. Except those parties appearing at the inquest which have a statutory duty to preserve all records, the parties are directed to destroy copies of exhibit 13A in these proceedings at the conclusion of the inquest, and any appeal or review.

Summary: Mr Al Jhelie was 21-years of age when he died on 5 September 20281 from complications of ligature compression of the neck (hanging) at Royal Perth Hospital. Prior to his death, Mr Al Jhelie had been held in immigration detention at Yongah Hill Immigration Detention Centre.

Mr Al Jhelie was born in Iraq and moved with his family to Jordan when he was a young child due to his family being targeted by the authorities. He lived in Jordan until 2010, when he moved to Australia on a global special humanitarian visa. He was 13 years of age. Mr Al Jhelie had difficulty settling into life in Australia. He was expelled from school, and fell in with a bad crowd and started using drugs and getting in trouble with the law. At a young age, he also formed two different relationships, from which he had three children in total.

In 2015, Mr Al Jhelie was sentenced to a term of imprisonment. He was released on parole in September 2016 and was immediately taken into immigration detention as his visa had been automatically cancelled under s. 501(3A) of the Migration Act (Cth) due to his prison sentence. He spent 101 days in detention before his visa was reinstated and he was released into the community on 9 January 2017.

Mr Al Jhelie reoffended not long after and he was sentenced to another term of imprisonment on 2 March 2017. His visa was again mandatorily cancelled, and he returned to immigration detention after his release from prison on 1 March 2018. Mr Al Jhelie had already applied to the Administrative Appeal Tribunal for a review of the decision not to (in effect) grant him another visa. In January 2018 the AAT set aside the decision not to revoke the cancellation of his visa and referred his case back to the Minister to reconsider after obtaining a psychiatric report on Mr Al Jhelie’s prospects of successful rehabilitation. There were significant delays in obtaining that report, and Mr Al Jhelie eventually hanged himself the day before he was due to meet the psychiatrist in order to prepare the report.

While in detention, Mr Al Jhelie had ongoing bowel issues, that caused him pain and distress, and he was having investigations to try and diagnose the cause of his symptoms. However, a colonoscopy did in May 2018 was only limited due to poor bowel preparation and needed to be repeated. A repeat colonoscopy had not been performed prior to Mr Al Jhelie’s death.

Mr Al Jhelie was initially held in Villawood Immigration Detention Centre in NSW. In July 2018, he was taken to hospital for treatment following two separate drug overdoses. There was conflicting evidence about whether Mr Al Jhelie’s two drug overdoses were deliberate acts of self-harm, but he was still offered a plan for psychological and drug and alcohol counselling, which he accepted. The Australian Border Force officers responsible for the good management of the detention centre and the safety of the detainees, were unaware of the medical and allied health support being offered to Mr Al Jhelie, so they arranged a transfer for Mr Al Jhelie with the intention of disrupting his drug supply. The transfer, which occurred on 7 August 2018, appears to have had the desired effect of limiting Mr Al Jhelie’s access to drugs, but also had the unfortunate consequence of moving him far away from his family and disrupting the planned medical support for his mental health and drug and alcohol issues. Mr Al Jhelie did not see a nurse or doctor until 29 August 2018, when he saw a doctor with a complaint of a 16 mth history of rectal bleeding with abdominal pain. Steps were initiated to arrange his repeat colonoscopy. Two days later, on 31 August 2018, Mr Al Jhelie was taken to Northam Hospital due to his abdominal pain and rectal bleeding. He was discharged back to the detention centre on 1 September 2018 after his pain settled.

Later that morning, Mr Al Jhelie had a fight with his fiancée and she reportedly ended their relationship and blocked his access to his phone, which was in her name. Mr Al Jhelie self-harmed by cutting himself and sent pictures of his cuts to his fiancée with his roommate’s phone. Serco officers were notified and they went and spoke to Mr Al Jhelie and took him to the pharmacy, where two IHMS nurses were dispensing medication. As it was the weekend, the nurses were not contracted to provide treatment to detainees, but the nurses looked at the cuts and determined them to be superficial scratches that did not require further first aid. One of the nurses also spoke briefly to Mr Al Jhelie to ask if he wanted to talk to her about what was bothering him, but he declined and told her he was feeling better. Mr Al Jhelie was returned to his room by Serco officers and the nurse made a note in the records that he should be followed up for a mental health review the next day. Later that afternoon, when Mr Al Jhelie’s roommate left the room to go and get some dinner, Mr Al Jhelie took the opportunity while he was alone to hang himself with a bedsheet.

When the roommate returned, the door was locked, so he asked a Serco officer to unlock the door for him. The Serco officer, the roommate and another detainee were present when the door was opened and Mr Al Jhelie was found hanging. They immediately cut him down and commenced CPR, which was continued by other Serco officers until ambulance officers arrived and took over his care. Mr Al Jhelie was taken to Northam Hospital and then transferred to Royal Perth Hospital, where he received intensive medical treatment. Sadly, investigations showed he had suffered an unsurvivable brain injury, and he died on 5 September 2018

The coroner found that Mr Al Jhelie died as a result of complications from hanging and that the death was by way of suicide.

The coroner made adverse comments about the failure to arrange the AAT ordered psychiatric report in a timely manner, the processes around the decision to transfer Mr Al Jhelie to Yongah Hill, the lack of continuity in Mr Al Jhelie’s medical care after his transfer to Yongah Hill and the lack of onsite medical staff for detainees at Yongah Hill during evenings and on weekends.

The coroner did not make any recommendations, but did make comments about improvements that need to be made in communication between the various stakeholders involved in the care and supervision of detainees in Commonwealth Immigration Detention Centres.

Catch Words : Death in Custody : Hanging : Suicide Immigration Detention Centre:

Last updated: 8-Aug-2022

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