Coronial
VICother

Finding into death of Muhammad Jaffar Hassan

Deceased

Muhammad Jaffar Hassan

Demographics

45y, male

Date of death

2018-10-09

Finding date

2022-10-10

Cause of death

Plastic bag asphyxia

AI-generated summary

Muhammad Jaffar Hassan, aged 45, died in custody at Metropolitan Remand Centre by plastic bag asphyxia on 9 October 2018. He was remanded for murder following the death of his partner Ms Fatima Batool. Clinical assessment in MAP and MRC indicated depression and anxiety with initial P1/S3 ratings, downgraded to P2/S4 by 24 July 2018. Mental health care met minimum standards; however, Mr Hassan declined psychiatric appointments at MRC and received no pharmacological treatment. The coroner found Mr Hassan intended to end his life. Key systemic issues identified: uncontrolled access to plastic bags in mainstream units despite nine prior incidents of plastic bag asphyxiation between 2014-2018; unclear handover processes for psychiatric appointments during inter-prison transfer; and gaps in formalised mental health care coordination. Corrections Victoria implemented interim measures to account for plastic bags and improve appointment scheduling systems.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

psychiatryforensic medicinecorrectional health

Error types

systemcommunication

Clinical conditions

depressionanxietytraumaacute adjustment disorder to custody

Contributing factors

  • uncontrolled access to plastic bags in prison accommodation units
  • downgrading of suicide risk rating from S3 to S4 on 24 July 2018
  • lack of active mental health treatment at MRC despite documented depression and anxiety
  • prisoner declining psychiatric appointments
  • unclear handover processes for scheduled psychiatric appointments during inter-prison transfer
  • no formal compulsory treatment available as prisoner not subject to involuntary Mental Health Act order

Coroner's recommendations

  1. Corrections Victoria to amend Commissioners Requirements 2.3.1 to ensure management of all spare plastic bags (including pack bags) is in line with existing policy for bin liners and garbage bags
  2. Corrections Victoria to amend Commissioners Requirements 2.3.1 and reinforce measures to encourage use of alternatives to plastic bags for safety and environmental purposes
  3. Implement formalised handover processes for psychiatric appointments scheduled at one facility to be reliably rescheduled at receiving facility following inter-prison transfer
  4. Develop comprehensive mental health care plans covering immediate assessment, collateral information, risks, family and social supports, NDIS recognition, discharge planning and prisoner goals
Full text
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