Inquest into the Death of Fazel CHEGENI NEJAD

Contributing factors

• prolonged indefinite immigration detention
• lack of continuity of psychiatric care across multiple facility transfers
• absence of regular in-person psychiatric assessment at Christmas Island
• failure to recognise escape alarm due to inexperienced control room staff
• mental health deterioration exacerbated by complex immigration pathway and repeated facility transfers
• possible serotonin syndrome from unprescribed Deptran tablet
• pre-existing vulnerabilities: history of torture and trauma in Iran, low education, prior substance abuse

Coroner's recommendations

1. The Department/Commonwealth should work together with IHMS to make it a contractual requirement for IHMS to ensure that a psychiatrist is available to provide in-person psychiatric assessments at Christmas Island for detainees at least on a fortnightly basis, acknowledging the practicalities of limited flight services to the island.
2. The Department/Commonwealth should work together with IHMS to make it a contractual requirement with IHMS that there be an increase in the number of mental health clinicians at Christmas Island than was the case at the time of Mr Chegeni Nejad's death, so that there is a reduced delay between requests for medical attention and appointments. Clinical governance of the provision of mental health services by the mental health team should also be supervised by a psychiatrist.