Inquest into the death of Muhammad Hafizuddin Bin Zaini
Deceased
Muhammad Hafizuddin Bin Zaini
Demographics
29y, male
Coroner
Decision ofDeputy State Coroner Ryan
Date of death
2020-12-12
Finding date
2025-03-06
Cause of death
hanging
AI-generated summary
Muhammad Hafizuddin Bin Zaini, a 29-year-old detainee in immigration detention at Villawood, died by hanging on 12 December 2020. He had a history of substance-induced psychotic disorder and was prescribed antipsychotic medication. The inquest examined whether his mental health care was adequate and whether communication regarding repatriation was appropriate. Expert psychiatric evidence confirmed his mental health monitoring and treatment were adequate. He received multiple mental health assessments, though compliance with medication and appointments was inconsistent. The coroner found no basis for predicting his suicide risk and accepted that the responsible psychiatrist's assessment of low suicide risk was reasonable. However, deficiencies in communication about his removal to Malaysia were identified. The coroner found it was not possible to foresee this particular risk and recommended reviews of communication processes and ligature risks in detention facilities.
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Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- mental illness with substance-induced psychosis
- inadequate communication regarding repatriation timeline and status
- psychological distress from indeterminate detention period
- mother's illness in Malaysia
- inconsistent medication compliance
- missed psychiatric appointments
- frustration and distress from perceived false information about departure date
Coroner's recommendations
- That the Commonwealth review the role of a detainee's Status Resolution Officer under the 2023 Procedural Instruction with a view to considering whether there is an opportunity to improve the process concerning: (a) the manner in which news or messages which, it might reasonably be expected, will be distressing to a detainee are communicated to that detainee; and (b) the support provided to a detainee at a time when that detainee is delivered news or messages referred to in paragraph (a) above.
- That as a matter of priority, the Commonwealth: (a) extend its 'ligature review' to all accommodation and bathroom areas within the VIDC as part of an Administrative Capital Works project; and (b) commit to taking reasonable steps to remove ligature points identified in the ligature review.
Full text
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