Inquest into the death of Muhammad Heri
Deceased
Muhammad Heri
Demographics
37y, male
Date of death
2005-04-28
Finding date
2006-03-03
Cause of death
Coronary Atherosclerosis
AI-generated summary
Muhammad Heri, a 37-year-old Indonesian fisherman, died from coronary atherosclerosis while detained in Darwin Harbour on 28 April 2005. He had been held on his fishing vessel for 7 days without medical examination following apprehension for illegal fishing. He collapsed after complaining of back pain and vomiting, dying before ambulance arrival. The autopsy revealed significant coronary artery disease, brain artery stenosis, and acute heart failure. Clinically, the underlying cardiac condition would likely not have been detected by routine examination. However, the coroner found the deceased had not received the medical examination stipulated in DIMIA guidelines (preferably within 24 hours). Key lessons include: establishing mandatory medical assessment within 24 hours for all detained foreign nationals, ensuring duty of care protocols are followed, and implementing timely health screening to identify serious conditions. The coroner commended improvements made since a previous similar death and recommended thorough medical examination as a fundamental duty of care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Absence of medical examination during 7-day detention period
- Non-adherence to DIMIA guideline of medical examination within 24 hours of detention
- Pre-existing significant coronary artery disease undetected
- Pre-existing brain artery stenosis
- Acute heart failure
Coroner's recommendations
- All detained foreign fishermen (those to be repatriated and those to be charged) should be thoroughly medically examined by a medical practitioner within 24 hours of reception into the detention facility
- DIMIA guidelines stipulating medical examination preferably within 24 hours should be made prescriptive rather than preferential
- The 24-hour medical examination requirement should be implemented to ensure the Federal Government's duty of care to detained foreign nationals and to address public health and safety concerns
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