Inquest into the Death of Sarwan Hekmat Salman AL JHELIE
Deceased
Sarwan Hekmat Salman AL JHELIE
Demographics
21y, male
Date of death
2018-09-05
Finding date
2022-07-15
Cause of death
complications of ligature compression of the neck (hanging)
AI-generated summary
Sarwan Al Jhelie, a 21-year-old Iraqi-born man in immigration detention, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose attempts. Key clinical lessons include: the failure to maintain continuity of mental health care after his transfer to Yongah Hill detention centre away from family and established supports; failure to initiate appropriate follow-up despite prior overdoses and psychiatric vulnerability; failure to obtain a court-ordered psychiatric assessment in timely fashion; and inadequate communication and coordination between multiple agencies (Department, Serco, IHMS) managing his care. The coroner found his mental health deteriorated significantly after transfer, and whilst the self-harm act on 2 September 2018 was likely superficial and attention-seeking rather than a suicide attempt, it should have triggered enhanced monitoring. However, even proper escalation and monitoring may not have prevented the impulsive act that evening.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- transfer from Villawood to Yongah Hill away from family and established supports
- failure to continue mental health and drug and alcohol counselling after transfer
- failure to obtain court-ordered psychiatric assessment in timely manner
- inadequate handover of care plan to Yongah Hill health staff
- lack of communication and coordination between Department, Serco and IHMS
- delay in diagnosis and treatment of chronic bowel condition
- separation from family and emotional supports
- untreated trauma and PTSD
- history of depression, drug abuse, and prior self-harm
- uncertain immigration status and fear of deportation
- recent breakdown of relationship with girlfriend
Coroner's recommendations
- The Department, IHMS, and Serco should establish a practice direction for coronial investigations to ensure early and orderly provision of relevant information to the Court
- The Department should improve communication and information sharing between its various business areas (SROs, NCCC, National Placements Team, Detention Operations)
- SROs should be equipped with comprehensive information about barriers to status resolution and should proactively inform detainees of progress in their cases
- IHMS should implement procedures to ensure that upon transfer of a detainee between facilities, a comprehensive health transfer assessment is conducted and a treatment plan is established and communicated to staff at the new facility
- IHMS should ensure that any handover of care plans occurs between health service managers at transferring and receiving facilities
- IHMS should ensure that a full health induction assessment is conducted when a detainee transfers between facilities, not just new admissions
- IHMS should ensure that when a forensic psychiatric appointment is pending, this information is documented in Apollo and included on the Fitness to Travel form
- The Department should strengthen procedures for obtaining legally required medical reports with clear assignment of responsibility
- IHMS should strengthen stakeholder and medical input to transfer decisions for detainees at risk of self-harm
- IHMS should implement a clinical assurance model within health services contracts
- IHMS should conduct root cause analyses in all cases of self-harm
- IHMS should conduct weekly reviews with medical directors to discuss key clinical cases
- IHMS should ensure that disclosures of torture and trauma history trigger incident reporting and referral to torture and trauma services
- IHMS should ensure that any act of self-harm triggers the Support Monitoring and Engagement (SME) process and generates an incident report
- Consideration should be given to the adequacy of weekend health service provision given the high prevalence of mental health issues in detention facilities
- The Department should reconsider the contractual arrangements regarding weekend health services at immigration detention facilities
Full text
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