Inquest into the death of Mansur La ibu
Deceased
Mansur La Ibu
Demographics
20y, male
Date of death
2003-02-26
Finding date
2004-03-19
Cause of death
Undetermined cause (seizure-like episode with rapid death, epilepsy ruled out on balance of probabilities)
AI-generated summary
Mansur La Ibu, a 20-year-old Indonesian fisherman, died suddenly on 26 February 2003 while detained on the fishing vessel Yamdena moored at Darwin Harbour. He experienced a seizure-like episode while confined in a small cabin (approximately 3 by 4-5 feet) shared with six other crew members during severe weather. The cause of death remained undetermined despite autopsy; epilepsy was ruled out on balance of probabilities. Death occurred very rapidly (within minutes). The coroner found no evidence of negligence in the immediate emergency response. However, significant systemic issues were identified: the deceased was held in immigration detention without charges for weeks in unacceptable confined conditions on an unseaworthy vessel; jurisdiction gaps meant the death was not investigated as a death in custody; and his Muslim burial was delayed inappropriately for four months due to lack of protocols between agencies. The coroner emphasised that detention of foreign fishermen without charges by federal agencies raised serious human rights concerns and that repatriation protocols and better detention standards were essential.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Confined living conditions on vessel (7 men in cabin approximately 3 by 4-5 feet)
- Severe stormy weather preventing immediate resuscitation
- Prolonged detention in immigration custody without charges
- Delayed or unclear emergency communication protocols
- Lack of jurisdiction clarity regarding deaths in immigration detention
Coroner's recommendations
- Amend the Coroners Act to define 'death in custody' to include deaths in immigration detention or any form of detention in the Northern Territory brought about by Commonwealth Laws, to enable greater investigatory powers and mandated police investigation
- Repatriate detained crew members who are not charged with any offence as soon as reasonably practicable to their home region or port of origin, without depending on their consent
- Improve detention standards: do not hold multiple crew members in confined spaces such as the Yamdena cabin for extended periods
- AFMA to conduct a full and complete review of all issues involved in this case
- Provide vessels and crews detained in the detention area with a horn, sounding or other signalling device for emergencies
- AFMA and DIMIA devise a protocol to deal with the Indonesian Consulate regarding burial and/or repatriation of bodies of Indonesian fishermen who die in immigration detention or detention under Commonwealth Fisheries legislation, with clear assignment of responsibility
Full text
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