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Matters of Appearance: Black Lives Matter and Decolonising Visual Culture in Nyungar Boodjah

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Saying Their Names, Fremantle

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“Incompatible with Survival”

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Dispatch Perth – Police Pursuit Inquest

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Deathscapes Symposium and Website Launch in Sydney

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Dispatch Perth – Mohammad Nasim Najafi’s Inquest

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Dispatch Perth – Ali Jaffari’s Inquest

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Dispatch: The Recent Derbal Yerrigan Drownings and “Aboriginal Deaths-in-Custody”

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Repetitions of violence: on David Dungay’s and Fazel Chegeni Nejad’s inquests

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Dispatch: Fazel Chegeni Nejad's Inquest

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Dispatch: David Dungay's Inquest

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Memorial Event to Celebrate Ray Jackson

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Statements for Ms Dhu, Survival Day, 26 January 2017

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RAPBS Call to Account, Melbourne, Sydney & Fremantle, December 2015

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Institutional Racism Kills: From John Pat … to Mr Ward, Public Forum, Perth, September 2009

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Women Report Violence in a Time of War: The Silenced Voices of the ‘Race Election’ – 8th November, 2001


A free panel discussion as part of the John Curtin Gallery Speaker Series for 50fifty:2020

Wednesday 26 August 2020
5:30pm – 7:30pm at John Curtin Gallery, Building 200A, Bentley Campus

Opening Address 

INGRID CUMMING, Nyungar Cultural Advisor, Curtin University


HANNAH McGLADE (Curtin University): “Monuments and the decolonization of public spaces in Noongar Boodjah”

MICHELLE BROUN (Museum of Western Australia): “Timeliness and Visual Truth-telling”

SHAHEEN HUGHES (Museum of Freedom and Tolerance, WA): “Saying their names: Creative activism in the pursuit of decolonising civic space globally”

ANNA ARABINDAN-KESSON (Princeton University) “Re-sighting History: Artists, Activism and Public Memory”

    Convenor: SUVENDRINI PERERA (Curtin University)

Projectionist: Steven Aliyan

The political scientist Hannah Arendt uses the term ‘space of appearance’ to suggest public political space where we interact and ‘appear’ to one another as political actors. More recently, the visual theorist Nicholas Mirzoeff uses the term ‘space of appearance’ to describe the global emergence of the BLM movement. Through a series of creative and performative actions (die-ins, public iterations of phrases such as ‘I can’t breathe’ and ‘Hands up, don’t shoot’), BLM protesters made hitherto largely invisible dimensions of police violence ‘seeable’ or perceptible to a larger public. Similarly, racialised deaths and Deaths in Custody have claimed a space of appearance in public debates in Australia through diverse visual and performative projects such as the Newcastle University Indigenous Massacre Map and the Deathscapes project.

As the Black Lives Matter movement continues to transform global consciousness, questions of everyday visual culture and the decolonization of public space have come to the fore. Locally, in solidarity with the BLM protests, the names of some of the hundreds of Indigenous people who have died in custody were projected on a landmark sculpture by Marcus Canning, known as the Rainbow (or Containbow) and located at 1 Canning Highway in Walyalup (Fremantle). The projections bring into focus relations of place, visibility, history and the resonance of the BLM movement in WA, the state with the largest number of Indigenous deaths in custody. The panel discusses the meaning and significance of this visual projection and broader questions of political ‘appearance’, creative activism and the decolonization of visual culture and public space in Nyungar Boodjah.   

Free event.  Refreshments will be served.


ANNA ARABINDAN-KESSON is an Assistant Professor of African American and Black Diaspora Art at Princeton University. Her research and teaching focus on the intersection of visual culture, histories of race and empire, and their legacies today. She is working on projects about unfree labour and colonial medicine in the nineteenth-century which connect Australia, the Caribbean and the Americas. Her first book, Black Bodies, White Gold: Art, Cotton and Commerce in the Atlantic World will be published by Duke University Press early next year.

MICHELLE BROUN was born Perth, Western Australia. Her mother is Yindjibarndi from the Pilbara region of Western Australia.   She has Scottish ancestry on her father’s side- descending from the invaders of Nyoongar Boodja and something to be reconciled moving forward. Michelle studied Aboriginal and Intercultural Studies and Fine Arts at ECU.  She is a qualified cultural planner, and has worked as a free-lance artist, curator and writer, a Project and Policy Officer with the Department of Culture and the Arts, and CEO of an Indigenous publisher.  She managed the Indigenous Community Stories, an oral -history- on- film program at the Film and Television Institute of WA for 3 years, producing over 30 short films in partnership with Aboriginal Elders and communities across WA.  She currently works at the WA Museum as the Aboriginal and Torres Strait Islander Curator for the New Museum Project.  She is honoured to work alongside Elders and community, to create space for the voices of our people, share our rich cultures and histories with the broader community, to break down stereotypes and be a part of the truth- telling.   

SHAHEEN HUGHES is the CEO of the Museum of Freedom and Tolerance and is passionate about the role of creative activism and the pursuit of social justice through the creative arts. 

 HANNAH MCGLADE is a Noongar woman from Western Australia and her career has focused on justice for Aboriginal people, race discrimination law and practice, Aboriginal women and children, family violence and sexual assault. Currently Dr McGlade is a Senior Indigenous Research Fellow at Curtin University and an Advisor to the Noongar Council for Family Safety and Wellbeing. Dr McGlade is also a member of the UN Permanent Forum for Indigenous Issues, the Western Australia Mental Health Tribunal and the Medical Board of Australia.

SUVENDRINI PERERA is John Curtin Distinguished Professor of Cultural Studies in the School of Media, Creative Arts & Social Inquiry at Curtin University. She is the lead researcher on the Deathscapes Project.

SPECIAL THANKS: Museum of Freedom and Tolerance, WA;  School of Media, Creative Arts and Social Inquiry, Curtin University.


Saying Their Names, Fremantle

Ayman Qwaider and Suvendrini Perera

June 12, 2020

During the June 2020 global Black Lives Matter protests, the Deathscapes team orchestrated an event at which local residents, academics and activists collaborated with the Museum of Freedom and Tolerance WA and Projection Artist Steven Aliyan to project the names of some of the 437 Indigenous Australians who have died in custody on an iconic local sculpture in Fremantle, Western Australia. The sculpture, by Marcus Canning is known as the Rainbow (or sometimes Containbow). Located at 1 Canning Highway, it is a construction made up of shipping containers in the shape of a rainbow, a tribute to the city’s historic port.

The sculpture is located at a significant site that takes in the Derbal Yerigan (Swan River) and the harbour. Off the coastline is the island of Wadjemup (Rottnest Island), where hundreds of Aboriginal prisoners were held in the nineteenth century. Rottnest prison is now known as the largest deaths in custody site in Australia.  Western Australia is also the state in which the largest number of Aboriginal people have died in custody.

In a powerful opening speech Dr Hannah McGlade remembered her ancestors who were imprisoned on the island, and underlined the connections between forms of slavery in  Australia and other settler states such as the U.S. Another historic  local prison, The Roundhouse, she noted, echoes the architecture of the slave forts of West Africa: “The mass incarceration and criminalisation of Aboriginal people has been ongoing since colonisation and the first building that was enacted by the colony is The Roundhouse which was established to house Aboriginal incarcerated people who were resisting slavery.”

 ‘Our power comes not only from the people who are here but from the spirits that we cannot see. When we say their name, we invoke their presence.’

Melina Abdullah, leader Black Lives Matter, Los Angeles

Further Reading

‘Maybe the most important reason for writing is to prevent the erosion of time, so that memories will not be blown away by the wind. Write to register history and name each thing. Write what should not be forgotten.’

 Isabel Allende

Write what should not be forgotten by Shaheen Hughes, Museum of Freedom and Tolerance WA

Saying their names in  Minneapolis by Soo Kim, Newsweek

Kaya Nidja Noongar Boodjah Speech at Perth Black Lives Matter Protest Hannah McGlade, Curtin University


Video by Dominic Pearce


Between the river and the sea, overlooking the port of Fremantle, with the largest deaths in custody site in Australia in the distance, this is a site that carries layers of historical significance.

Directly above is Cantonment Hill, the seat of military occupation, reminding us of the colonial monuments being pulled down across the world. The names of Indigenous people who have died projected on the Rainbow Sea Container bring these sites and their effaced layers of violence into focus anew.

Suvendrini Perera

Thanks to:
Dr Hannah McGlade; Shaheen Hughes, Zoe O’Neill, Museum of Freedom and Tolerance WA; Steven Aliyan; Dr Antonio Traverso; Dominic Pearce; Dr Thor Kerr; Kerry Fletcher; Councillor Rachel Pemberton, City of Fremantle; Anonymous Drone Photographer; School of Media, Creative Arts and Social Inquiry, Curtin University

“Incompatible with Survival”: The Coronial Inquest Findings into the Aboriginal Death in Custody of David Dungay

Suvendrini Perera and Joseph Pugliese


Legal procedure is presented as the cornerstone in the fair and equitable administration of justice. It is what rigorously regulates the methods through which the legal process unfolds and what determines what will be admissible as legal evidence. This understanding of the value of legal procedure is, we contend, profoundly unsettled when situated in the context of coronial inquest findings into Aboriginal deaths in custody, specifically, with reference to the findings on the death in custody of David Dungay, a young Dunghutti man who was killed in the process of a cell transfer at Long Bay Hospital, Long Bay Correctional Centre. Following our close examination of the findings, we argue that legal procedure, as invoked and deployed in the context of the findings, serves to present the rational and orderly administration of legal process while, at the same time, obfuscating a range of violent racial relations of power that remain unspeakable in the text of the findings, even as they insistently inscribe and underpin the very letter of settler law.

David Dungay is described by his family as someone who was “happy-go-lucky and loving. He had a talent for writing poetry and an ability to convey enormous meaning with his poems. David was extremely loyal and dependable, willing to give up his own time for his siblings, and to always be there for them when they needed him.”[1] Yet David Dungay’s short life also traces an acutely painful trajectory marked by the early onset of chronic schizophrenia and a range of other health ailments, including diabetes and asthma. This trajectory, as it is outlined in the custodial history presented in the findings, is inscribed and largely overwritten by his entry into the settler carceral system, his struggle with serious episodes of untreated psychosis, and his shuttling through different prisons before his fatal entry into Long Bay Hospital at Long Bay Correctional Centre.

On the afternoon of the 29 December 2015, on his return from the prison exercise yard, David purchased a packet of biscuits and was locked in his cell. Two officers (identified as Officers E and F) then proceeded unsuccessfully to persuade David to relinquish his biscuits as they were apparently concerned about his blood sugar levels due to his diabetic condition. David became increasingly agitated and aggressive at this point, refusing to give up his biscuits. Officers E and F then decided to call in the Immediate Action Team (IAT) to forcibly remove David from his cell and move him to another cell with a camera so he could be monitored. This move was done on the pretext that both officers believed that the situation was tantamount to a “medical emergency.” Yet, as is evidenced throughout the course of the findings, at no point did the officers receive official confirmation from any of the Justice Health nurses working in the correctional hospital that David’s health situation constituted a “medical emergency.” At this point, the two officers had two crucial options that they could have deployed in order to de-escalate the situation: 1) they could have called on an Indigenous Liaison Officer, armed with appropriate cultural protocols, to calm David and get him to hand over the biscuits; and 2) they could have called on one of the psychiatric nurses in order to assist in defusing the situation. Rather than pursue these appropriate and available options, the two officers called in the most extreme of all options: the riot-clad IAT to forcibly extract David from his cell. Another available option included having the IAT secure David and simply remove the biscuits from his cell. This option was never considered.

Before entering the cell, the IAT officers issued David two proclamations demanding he “come to the door, place his hands through the door so that he could be handcuffed and then moved to another cell.”[2] For each proclamation, the IAT gave David 30 seconds to one minute to comply. The IAT in fact viewed their issuing of these two short proclamations as evidence of their use of a “de-escalation” technique, thereby completely effacing the fact that they were dealing with a mentally ill person actually housed in the mental health ward of a prison: “the proclamation given to David by the IAT to comply with their directions within one minute, prior to entering the [sic] David’s cell, amounted to negotiation and a risk management strategy.”[3] The disturbed state of David’s mental health is evidenced by the fact that he not only disregarded their proclamation, despite the threat issued from the IAT that “force may be used,” but that he then proceeded to pull “his shirt over his head and appeared to shadow box.”[4] Clearer evidence of David’s agitated mental state could not have been presented to the IAT officers.

On entry of the IAT into the cell, David collided with the riot shield of one of the officers, and he was then forcibly restrained and pinned down on his cell bed. It is from this point onwards that David begins to articulate what will become an increasingly urgent refrain: “I can’t breathe.” As the findings note: “He repeated those words on a number of occasions while he was in cell 71, while being transferred to Cell 77 and inside Cell 77”[5] – all, we underscore, to no effect. The violent practices that were inflicted upon David’s person by the IAT were captured on the officers’ body cameras and CCTV footage. Handcuffed and with his head pressed down, in the process of the cell transfer David begins to spit blood, drops to his knees and screams that he can’t breathe. The officers coolly reply that if he can speak, he can breathe and also “remonstrate with David to stand up and stop spitting blood.”[6] In the course of the inquest, the officers term David’s urgent cries that he can’t breathe as “diversionary tactics.”[7]

Once led into cell 77, David “was placed onto the bed face down and was again restrained by the IAT officers placing weight onto him,” while a Registered Nurse (RN) Xu “entered and administered an injection of midazolam into David’s right buttock” in order to sedate him: “David continued to scream that he could not breathe while RN Xu was in the cell.”[8] Continuing to disregard David’s screams, the “officers observed that David appeared to be breathing and said to him that as he was talking, he was breathing.”[9] Yet, “Approximately 60 to 90 seconds after the midazolam injection was administered, David became unresponsive and CSNSW officers described his body going limp.”[10] What followed where botched and wholly incompetent attempts to resuscitate David. David was “pronounced deceased at 3.42pm.”[11] In the space of less than an hour, a young Aboriginal man died at the hands of the authorities of the state.

One of the inquest’s key conclusions states that: “Ultimately, it was neither necessary nor appropriate for David to be moved.”[12] The Dungay Family solicitor, in the course of the inquest, “submitted that Officer F embarked on a ‘power play’ in response to David’s defiant behaviour, which can only be described as repugnant and reprehensible.” Magistrate Derek Lee, in his 13.16 Conclusion, dismisses this submission by stating that: “it could not be said that this is the only reasonable conclusion that could be drawn from Officer F’s decision to effect a cell transfer for David.”[13] Magistrate Lee’s 13.16 Conclusion stands in contradiction to his 14.12 Conclusion where he states that: “The evidence establishes that there was no proper basis for Officer F to request the attendance of the IAT in G Ward on 29 December 2015. None of the criteria … relating to the roles and responsibilities of the IAT provided for their involvement in a medical issue, as understood by Officer F. On this basis alone, it can be concluded that it was neither necessary nor appropriate to utilise the IAT to facilitate David’s cell transfer.”[14] Furthermore, in his 14.13 Conclusion, Magistrate Lee emphasises that it was unnecessary for Officer F to call in the IAT as “the evidence clearly establishes that David was secured within his cell, with no security issues present.”[15] If it was neither necessary nor appropriate to utilise the IAT forcibly to remove David from his cell, why then was not a power play at work?

In our critical reading of the events that transpired to kill David Dungay in the process of his forced cell transfer, we contend that not only was an asymmetrical power play at work, but that this unequal power play was always already racialised as it was a case of non-Indigenous correctional officers dealing with a Black prisoner whose power status was further eroded due the fact that he was suffering from chronic mental illness. In fact, nowhere in entirety of these coronial findings is the question of racism ever raised. It is the absolutely unspeakable fact. And yet it insistently underpins so many of the violent relations of power that were exercised by the settler carceral system and its agents in the killing of David Dungay.  For us, racism informs and scripts the failure to take into account David’s chronically agitated mental state prior to the entry of the IAT into his cell; by disregarding his mental illness, he is framed by the correctional officers as a violent troublemaker. Racism informs the failure to call in an Aboriginal Liaison Officer to de-escalate the situation. Racism, as a form of violent “power play,” drives the use of exorbitant force on David’s person: he is seen as an intrinsically recalcitrant subject who needs to be beaten into submission and punished through a forced cell extraction. Racism underpins the blithe dismissal by the correctional officers of David’s desperate cries that he can’t breathe: as a Black man, he is framed as a mere malingerer who is obviously “faking” it and who is trying to “play the system.” As one of the officer’s states: “he did not see anything from his observations to think that the complaints were genuine.”[16] We emphasise the word “genuine” as it brings into focus the racialised power dynamics that serially script the manner in which incarcerated Aboriginal women and men, who are suffering from medical conditions, are fatally denied the due medical care and attention that would otherwise be administered to sick prisoners. The catalogue of this racialised discrimination and failure to offer proper due medical care to Indigenous people in custodial settings includes Ms Dhu, Ms Tanya Day, Ms AT, Mr Nathan Reynolds, Mr Yeeda and Mr Wayne Fella Morrison. The Deaths Inside: Indigenous Australians Deaths in Custody database documents 72 cases of Indigenous people who have died in custody due unattended medical issues.[17]

Operative in the killing of David Dungay was an excess violence licensed by a form of racism that views Aboriginal prisoners as in need of inordinate form of control and restraint. In 16.18 Conclusion, for example, Magistrate Lee states that, “By Officer C’s own acknowledgement, David was adequately restrained on the bed in cell 77 when the knee ride continued to be applied. Consistent with the provisions of the OPM, the application of such additional force was not warranted in circumstances where satisfactory restraint had been achieved.”[18] Despite this acknowledgement of the unwarranted nature of the “additional force” that was used against David, none of the officers was held to account in line with the Dungay Family solicitor submitting that: “a referral ought to be made the NSW Director of Public Prosecutions pursuant to section 78(4) of the Act with respect to the conduct” of a number of the officers involved in the death of David. A number of the officers had, during the course of the inquest, stated that they would only give evidence if they were issued, as was the case, “with a certificate pursuant to section 61(5) preventing their evidence from being used against them (except in relation to criminal proceedings in relation to the falsity of their evidence).”[19] As the certificates of exemption had been issued, Magistrate Lee concludes that: “It would be procedurally unfair to now consider the submissions made by the solicitor for the Dungay Family regarding the possibility of the officers being “convicted for an indictable offence that is causally related to the death of the person who the inquest is concerned with.”[20] The issue of “procedural fairness” must be seen here as inscribed by an asymmetry of racialised power: justice cannot be served for David Dungay when the very officers who were responsible for his death cannot be convicted for any possible criminal actions due to the issuing of “certificates of exemption.”

The Dungay Family solicitor also “submitted that Officer A failed to cease restraint and address David’s complaints of difficulty breathing, that Officer C used excessive force in maintaining restraint, that Officer E failed to preserve evidence in cell 71 [which was cleaned of all evidence soon after David’s death], and that Officer F acted beyond power in deciding to move David from cell 71 to cell 77.”[21] To this catalogue of what one would assume were indictable offences that should be referred to the NSW Director of Public Prosecutions, Magistrate Lee replies that: “It has already been noted that the conduct of the IAT officers was limited by systemic deficiencies in training which had been provided to them…. On this basis, the submission is not accepted.”[22] Everything here pivots on driving home the responsibility for the killing of David not to the actions of the officers but to “systemic deficiencies in training.” What remains unnamed in the broaching of the settler-colonial prison-industrial complex’s “systemic deficiencies” is the foundational role that systemic racism plays in generating those very lethal “systemic deficiencies” that result in the death of Aboriginal people in custody.

We can perhaps best evidence this assertion by invoking the words of the medical specialist, Professor Brown, who was called to give evidence on the quality of the medical assistance that was given to David Dungay during the process of his cell extraction and transfer. After listing a catalogue of systemic failures to offer appropriate medical care to David, “In summary, Professor Brown noted that the medical treatment provided by Justice Health staff overall ‘was of a low standard’ and lacking in essential aspects,’ and that the lack of provision of continuous basic life support ‘rendered the resuscitation attempts by Justice Health doctors and nurses effectively without value, and was incompatible with survival.’”[23] In concluding, we would transpose the final phrase of Professor Brown’s summary – “incompatible with survival” – as acutely materialising the systemic racialised forces that worked in the killing of David Dungay. The settler system of racialised incarceration, punishment and elimination of Indigenous people in this nation is, essentially, incompatible with their survival once they enter the carceral complex. And the “procedural fairness” of settler law masks the structural, because racialised, asymmetries of power that underpin it, that ensure its smooth reproduction, its ongoing violent impact on Indigenous people, and its systemic failure to deliver justice to its Indigenous victims and their families. Since the establishment of the Royal Commission into Aboriginal Death in Custody, no correctional or police officer in Australia has ever been successfully indicted with regard to an Indigenous death in custody.


[1] Coroner’s Court of New South Wales, Inquest findings into the death of David Dungay, 22 November 2019, p. 5. Available from:

[2] Ibid., p. 13.

[3] Ibid., p. 35.

[4] Ibid., p. 13.

[5] Ibid.

[6] Ibid.

[7] Ibid., p. 40.

[8] Ibid., p. 14.

[9] Ibid.

[10] Ibid.

[11] Ibid.

[12] Ibid., p. 27.

[13] Ibid.

[14] Ibid., p. 31.

[15] Ibid.

[16] Ibid., p. 41.

[17] Deaths Inside: Indigenous Australian Deaths in Custody 2019, The Guardian. Available from:

[18] Coroner’s Court of New South Wales, Inquest findings into the death of David Dungay, 22 November 2019, p. 45. Available from:

[19] Ibid., p. 46.

[20] Ibid.

[21] Ibid., p. 58.

[22] Ibid., p. 60.

[23] Ibid., p. 79.

Dispatch: Inquest into the deaths of Kyrone Eades, Amy-Lee Armstrong-Ugle and Ashley De Agrela

October 2nd 2019, Perth Central Law Courts, Courtroom 81

Dispatch by Michelle Bui


Almost four years on from a police pursuit in Cockburn, Western Australia, that culminated in the deaths of three people – Kyrone Eades (24), Amy-Lee Armstrong-Ugle (25) and Ashley De Agrela (19) – a coronial inquest hearing considered their deaths. The one-day hearing was overseen by Coroner Barry King who, as we previously wrote, presided over the inquest into Ali Jaffari’s death in immigration detention.

The families of two of the crash victims, Mr Eades and Ms Armstrong-Ugle, a young couple and parents to three children who are now in foster care, were represented by the Aboriginal Legal Service WA (ALS). Mr Eades’ Mother, Francina Wynne, as well as an Uncle, a few Aunties and some younger male relatives attended the inquest. Inside the courtroom, they were flanked by the typical markers of a deaths in custody inquest; blue uniforms and a squad of white bodies with Western Australian Police (WAPOL) lanyards around their necks. Shortly after the proceedings commenced, a woman entered the court and sat in the first row directly in front of Francina Wynne. Her laptop opened to reveal the WAPOL insignia, which incorporates the same state coat of arms that the Coroner sat beneath.  As I looked around at the bodies that filled the space, I wondered how the family felt being surrounded by people who are employed to uphold a racist institution that routinely targets and kills Aboriginal and Torres Strait Islander people with impunity.

It was purported that they key consideration of the inquest would be what role WAPOL played in the deaths of Mr Eades, Ms Armstrong-Ugle and Mr De Agrela, who were passengers in a vehicle they had been pursuing until shortly before it crashed. At some point between the opening of the inquest and when the first WAPOL witness began his emotional description of arriving at the crash scene, it became apparent that the dominant narrative of this inquest would be one where the tables were turned to position the perpetrators as the traumatised victims in need of care. I imagine that this must have been the logical interpretation of events from the perspective of the majority white court, who clearly demonstrated much more empathy for those two officers than for the family members sitting at the back of the courtroom. As the day went on it appeared increasingly unlikely that the Coroner would raise any substantial criticisms of the conduct of the WAPOL officers, nor would it be suggested that they were in any way accountable for these deaths. A familiar routine unfolded, where state actors worked to exonerate the police and in doing so reinforced the idea that the lives of Indigenous people are expendable.

In this case, as with many others, the inquest effectively reproduced and amplified the violent, racialised and asymmetrical relations of power between the now-dead victims and their families, and the police. While the voices of family members were silenced and sidelined, effectively given the prominence of a footnote, the evidence of the two WAPOL officers who drove the pursuing vehicle was centred, informing the trajectory of the inquest’s narrative and the corresponding media coverage.

The care afforded to both of the white, male WAPOL officers during the hearing contrasted significantly with the ways in which coroners courts have typically treated Aboriginal families. There was consistent acknowledgement of the trauma that the officers had experienced through the framing and nature of questions asked. They were treated with sensitivity and respect. The police were humanised through the process of giving evidence while the crash victims were represented merely as bodies: as objects of trauma, rather than individuals with lives, relationships and connections that extended far beyond what a court could ever contain.

The court’s positioning of the WAPOL officers translated into news headlines like, ‘”It was terrible”: Officer recounts horror of arriving at Cockburn crash after police pursuit’ on WA Today, ‘Police break down while recounting horrific fatal drug-fuelled pursuit crash’ on Channel 9 and ‘WA Police officer recalls “terrible” screams from crash wreck after fatal Perth high-speed chase’ on the ABC. In each of these headlines and the articles that follow, the emotional toll of the ‘incident’ on the WAPOL officers is centred. Rather than being named as actors complicit in orchestrating the horrific scene that unfolded, they are positioned as passive, traumatised witnesses who sacrificed their personal psychological wellbeing in the course of duty. In a clear demonstration of white privilege, their emotions were given significantly more weight than the grief of Mr Eades’ family which appeared to remain largely unintelligible to the court and a secondary issue to the journalists.

After being asked how his involvement in the pursuit and witnessing the crash scene had impacted him, the first WAPOL officer (Senior Constable Joel Vanson) who was driving the car was asked whether it has affected how he would respond now to similar incidents. He indicated that he’d ‘reluctantly’ engaged in pursuits since but that he had followed protocol in this instance and therefore wouldn’t have done anything differently nor would he respond differently in future. He stated that he was not deeply invested in policing traffic and pursuing vehicles and that rather his interest was in apprehending people who breach the law. It seems this opinion is not withstanding the fact that three people who had not breached the law were killed in the course of apprehending the one person who had. The sentiments of Senior Constable Vanson echo those of a Senior Constable involved in the fatal pursuit of 15 year old Benjamin Ware in 2011, who stated, ‘I’m paid to stop offenders and he was offending at the time.’ These responses suggest a pervasive culture within the police force where ‘law enforcement’ is held as the priority regardless of whether those who they criminalise are killed in the process.

The second officer (Senior Constable Darren Cramer) who was the passenger in the police car, presented similarly to the first officer; however, unlike Mr Vanson, he stated that he was aware there were passengers in the car they were pursuing. He described arriving at the scene of the crash and locating the front seat passenger who was seriously injured but still alive and then subsequently locating the bodies of Mr Eades and Ms Armstrong-Ugle who were strewn across the road and the pavement some distance from the car. After this he paused to note that ‘it might sound silly’ and that he didn’t mean to say this to disrespect the families but that one of the saddest parts he remembers is that amidst all the chaos ‘a f*cking little bird got knocked out of its nest’ and that this image has stayed with him. He choked up at this point. I thought it telling that he considered it necessary to mention this to the court, in the presence of family members who had just heard descriptions of their loved ones’ mangled bodies at the scene. Simultaneously shocking and unsurprising, it was as if he felt more closely connected to the bird than to the Black bodies of Mr Eades’ and Ms Armstrong-Ugle who were among the human casualties of their actions.

While the effects on both officers were noted and they talked about how horrific the crash was, counsel for WAPOL and the WAPOL witnesses refused to reflect on what an alternative response could be. Rather, the narrative was that they’d followed the book, they were ‘doing their job’ and unfortunately this resulted in a tragic loss of life. Such a tragic loss of life however did not warrant a review of protocols or change in policing culture – indeed they actively resisted this idea. In relation to another recent police pursuit inquest, Coroner King noted, ‘The police officers were trying to do their job…I can’t condemn them for doing what they did.’  The prosecutor in the same case, Sean Stocks, likewise stated, ‘If somebody dies it’s not the fault of the police for pursuing you, it’s your fault for not stopping.’ Here it appears that the courts can always be relied upon to reproduce the narrative that the police are faultless, this is business as usual and settler law is working exactly as intended.

It was highlighted in a 2017 inquest into the deaths of six people, that between 2010-2016 twenty-seven people died in crashes connected to police pursuits in WA. One of the people whose death was considered during this inquest was 23-year-old Aboriginal woman Ms Narrier who died in November 2014, when the car her partner was driving crashed into another vehicle. There are parallels to this case in that the driver was also drug-affected and the police terminated the pursuit when the vehicle moved to the wrong side of the road, just moments prior to the crash. State Coroner Fogliani concluded that the police did not cause or contribute to her death. This inquest only resulted in one recommendation, while no recommendations were made following the inquests of 15 year old Mr Ware and 13 year old Ms Samson.

In the final oral submissions, the ALS lawyer, Chloe Wood, submitted some statements by the family that described the impact that the deaths of Mr Eades and Ms Armstrong-Ugle has had on them and their children. The couple were described as happy people, full of life, who were greatly loved by their families and community. These remarks echoed previous comments from cousin, Katina Beresi, who shortly after the crash stated, ‘They were beautiful people. They were just getting a lift and (were) in the wrong place at the wrong time…I am really feeling for (the kids) as they are going to live with no parents now… I think the law should change in pursuing cars, because look what happened…We lost family members, and we have got to grieve for the rest of our lives.’

Following this brief opportunity for the families voices to be included, Australia’s racialised history of white paternalism was reproduced in the Coroner’s shocking and disrespectful final statements to the family. Rather than acknowledging the family’s loss and trauma in any meaningful way, Coroner King instead lectured them. He told them ‘keep your kids safe’ and suggested that they ensure their kids didn’t get into fast cars or take meth or accept rides with people taking meth. He said this as if it was the sole lesson to be derived from the inquest and in doing so shifted the blame onto the victims. His patronising advice was ridden with assumptions about the ability of Aboriginal women to parent their children and denied the reality that young Aboriginal people are targeted by police. To WAPOL he did not offer any unsolicited advice: after all they had been exonerated by his court and would no doubt continue to do their jobs. A job which, an Aunty suggested, amounts to ‘killing our kids’.


On 2 May 2019, a community symposium was held at The State Library of Western Australia in Perth entitled One of Us?: Complicity and Critique After The Christchurch Massacre.

The symposium was presented by The School of Media, Creative Arts and Social Inquiry, Curtin University, and The Museum of Freedom and Tolerance, WA.

Prime Minister Jacinda Ardern opened an official book of condolences for the victims of the Christchurch attacks with the words, they are us.

We, our, us, them are the most basic units of defining belonging and non-belonging. Prime Minister Jacinda Ardern chose to redefine these terms within her nation, claiming as kin the victims of the Christchurch massacre and disowning the killer. Yet, in other contexts, the killer was humanised, in line with his own self-representation as “an ordinary white man” — someone who could be “one of us.” In the case of the 2011 massacre in Norway, author Åsne Seierstad notes that descriptions of the killer emphasized qualities that made him appear less like one of us.

Following the Easter bombings in Sri Lanka, we again face questions of them and us as national and global tensions play out in new configurations of violence and terror.

Who are “we”? Who is “one of us”? Who are we part of? Whose humanity do we recognise as akin to ours?

In this symposium, community members, academics and artists consider the fraught term, one of us, exploring questions of the normalization of racism, everyday Islamophobia, and the connections between various forms of othering – “us and them” – in Australia and elsewhere.

We consider our complicities with violence and explore ways forward. A Q and A panel will address pre-submitted questions on how to recognize and resist the destructive identifications of us and them and the ways in which they are reproduced in our daily lives.

Featuring:  Randa Abdul-Fattah (video), Sky Croeser, Shaheen Hughes, Imam Yahiya Ibrahim, John Kinsella (video), Marilyn Metta, Marziya Mohammedali,  Suvendrini Perera, Ayman Qwaider, Sabah Rind,  Sara Saleh (video), Kim Scott, Rabia Siddique,  Fadzi Whande, Yirga Woldeyes.

Convenors: Shaheen Hughes, Hannah McGlade, Marziya Mohammedali,  Suvendrini Perera

Organising Committee: Michelle Bui, Sky Croeser, Thor Kerr, Marilyn Metta, Baden Offord, Ayman Qwaider, Antonio Traverso.

In his powerful speech in the Senate Senator Pat Dodson stated, “We turn our back against xenophobia, against hate crimes and against any gunmen who hold innocent people in their sights. We call out those who exploit fear and ignorance for political gain, who mock the traditional dress of women of another culture, who seek donations from the manufacturer of weapons of war to override our own laws and who argue that it’s all right to be white. Their actions and exhortations would plunge this country back into the killing times. You’ve got to remember that this history is well known to First Nations peoples.”


The symposium started with a video from the beautiful virtual garden of healing introduced by Shaheen Hughes and a smoking ceremony and Welcome to Country by Uncle Ben Taylor.

Video: Marziya Mohammedali.


The symposium began with an introduction by Rabia Siddique and a reflection by Suvendrini Perera about the concept of ‘One of Us’ in the context of the Easter attacks in Lanka.

‘In Lanka, there is no history of violence between Christians and Muslims. In recent years, rather, both these groups have been the target of Buddhist majoritarian extremism and violence; both cast as interlopers living on sufferance on the land that is the property of the latter. This is not so different, actually, from the premise of white supremacist thinking – that the land belongs to one specific group and that others are an unwanted presence to be removed; that they are interlopers.

In Lanka the ideologies of global Islamism, in which the Christian West is framed as the enemy, were projected onto a very different local environment where Islam and Christianity historically have co-existed. Contemplating the killing of Christians by Islamists … Lankan Christians and Muslims were both asking, in their different ways, Who are we? Who counts as one of us?

These words: We, our, us, are the most basic units of defining belonging and non-belonging.  They are fraught at every turn. “One of us’ is a double-edged sword of a term.  On the one hand it signifies kinship, comradeship, community. But community, as we know, also works as a form of exclusion, of a symbolic, and sometimes literal, refusal, casting out or annihilation of the other. One of us: it’s almost always a question as well as a statement —  or to put it another way:  within the affirmation ‘one of us’ is perhaps always already inherent a question, signaling the doubled edged nature of community itself.’



“One of Us?” – Complicity and critique after the Christchurch massacre 


Three Villanelles by John Kinsella

John Kinsella contributed via video three villanelles in response to the Christchurch massacre, the Easter attacks in Sri Lanka and the actions of white supremacists.

‘We write against violence, we write against intolerance, we write in solidarity with human life and all life. Fascist hatred has no part in it.’

On racism – a call for change

PANEL 1: Reflections

In the first panel, Chair Rabia Siddique asks panelists Sabah Rind, Kim Scott, Ayman Qwaider and Sky Croeser to reflect on what ‘One of Us’ means in the context of the recent massacres in Christchurch and Lanka.

Randa Abdul-Fattah and Sara Saleh contributed videos of their immediate responses following the Christchurch massacre.

Randa Abdul-Fattah: ‘We told you the threat is white supremacy. You ignored us’

Sara Saleh: ‘Christchurch and truth telling’

PANEL 2: Ways Forward

In this panel the Chair Yirga Gelaw Woldeyes, posed the question to panelists Dr Marilyn Metta, Imam Yahya Ibrahim and Fadzi Whande, ‘What can we do to prevent this kind of atrocities in the future?’

POEM: ‘This is not us…but it is’

by Marziya Mohammedali

On 16 February 2019 a one-day symposium was held at The Settlement in Sydney to launch the Deathscapes website. The program included a line-up of leading artists, academics and activists from across Australia

The deaths of Indigenous people in custody and the deaths of refugees at the border and in detention centres are connected by shared colonial histories, and by structures of sovereignty. Across the settler states of Australia, Canada and the U.S–as well as in the UK and the EU as their places of origin–the Deathscapes project analyses and documents the deaths of racialised groups in prisons, police cells and in on-shore and offshore detention camps.

Visual Minute of the Deathscapes Symposium by Anton Pulvirenti.


Craig Madden representing his father, Uncle Charles ‘Chicka’ Madden, welcomed attendees to Gadigal Country.

honouring elders

Suvendrini Perera and Joseph Pugliese introduced the project and paid tribute to the elders whose work to end deaths in custody had inspired them: Bandjulung author, Aunty Ruby Langford Ginibi, Noongar activists, Uncle Ben Cuimermara Taylor and  Aunty Helen Corbett, and, especially Wiradjuri activist Uncle Ray Jackson, an early partner on the research, who did not live to see its completion.

Uncle Ray Jackson’s daughters, Carolyne and Francine Jackson, spoke in remembrance of their father.


The Symposium began by remembering the people at the heart of this project: those who die in custody. Carolyne and Francine Jackson, daughters of the late Uncle Ray Jackson, and Dr Hannah McGlade joined Deathscapes team members (Michelle Bui, Pilar Kasat, Ayman Qwaider, Suvendrini Perera and Joseph Pugliese) on stage. In turn they read out the names or initials of nearly fifty Indigenous people and refugees who died in custody over the three years of the project.

PANEL 1: REsponses to the deathscapes site

The opening panel, chaired by EAB member Professor Chris Cunneen, asked each panelist firstly to respond to the aspects of the Deathscapes site they found most significant, and secondly to discuss how the site meshed with their work in their own disciplines.

The first speaker was Dr. Safdar Ahmed who highlighted the site’s focus on the politics of representation and the multidimensionality of refugee stories. He drew attention to the creative resistance practices adopted by people held at the Villawood detention centre and the function of art works included on the site. 

The second speaker, Professor Bronwyn Carlson spoke on trauma, the experiences of Aboriginal women in custody and racism in the so-called justice system. She highlighted how Aboriginal people are systematically removed from the land through mass incarceration.

In response to the second question, Professor Carlson reflected on how the site is an important resource for her students in Indigenous Studies. She spoke on the value of social media as a platform to disseminate information and allow Indigenous people to speak back to the absence of their stories in the mainstream media.

Dr. Maria Giannacopoulos referred to the use of the site in teaching Criminology and helping to articulate what the law doesn’t say. She spoke on teaching students about the ways in which racialised populations are targeted for punishment and criminalised.

She then spoke on how the Deathscapes site relates to her work examining how colonial laws and legal systems are implicated in producing violence against racialised populations and the concept of sovereign debt.

Dr. Hannah McGlade spoke on the site as a peoples’ record of stories and art. She reflected on the Royal Commission into Aboriginal Deaths in Custody and her personal experiences of contact with police and family and community members being taken into custody. She highlighted the case Ms Dhu and that of an Aboriginal woman who is currently serving a 12 year sentence of imprisonment for self-defense in a domestic violence case.

In response to the second question she reflected on how the site intersects with her work in the field of human rights law and the potential for the site to be used as a body of evidence and tool for accountability at the United Nations.


Behrouz Boochani is a globally recognised Kurdish writer, journalist, scholar, cultural advocate, filmmaker and human rights defender currently incarcerated by the Australian government on Manus Island. He recorded this video message for the Symposium with the assistance of his translator Omid Tofighian. He also provided an accompanying statement that was introduced and read on his behalf by Deathscapes researcher, Michelle Bui.


Dr Nicole Watson, a member of the EAB, chaired the keynote session, presented by Ryan Presley, an artist centrally concerned with questions of sovereignty and violence. The address noted points of connection between Ryan’s highly acclaimed Blood Money series and the Deathscapes project.

Video Forthcoming.


The Symposium closed with a brief statement and powerful poetry reading by Alison Whittaker.

Heartfelt thanks to Marisa Sposaro from 3CR Melbourne who recorded the first sessions of the symposium which were aired on the ‘Doin’ Time’ program.

Marisa Sposaro, The Settlement, Gadigal Country, 2019. Photo: Charandev Singh.


For more materials from the launch see @Deathscapes Symposium and Website Launch Twitter Moments.

selected media stories

‘Custody deaths in WA, Manus Island spark global “Deathscapes” project’, Sydney Morning Herald, by Emma Young

Deathscapes: mapping Indigenous, refugee and migrant deaths in custody’, SBS, by Bertrand Tungandame

‘Mapping Deaths in Custody to Dismantle Carceral Logic’, Overland, by Jordy Silverstein

‘Deathscapes project is ready to end deaths in custody’ Koori Mail February 13, 2019

special thanks from the deathscapes team to:

Co Nguyen and the staff at The Settlement for their assistance with the venue.

Dr Lara Palombo, Stephen James Houston and the Giannacopoulos family for their unstinting help and support on the day.

Flyer image credits (left to right):

Aunty Carol Roe outside Perth Coroner’s Court, Whadjuk Noongar Country (Perth), 2015. Photo: Charandev Singh. 19 July painting by woman detained on Nauru, 2017. Darren Turner, a member of the Gunditjmara nation, marching at the ‘SOS Manus Prison – End the Siege #SanctionAustralia’ Protest, Naarm, 2017. Photo: Charandev Singh. 

Villawood Fence, Refugee Art Project Surviving Detention Series, Villawood NSW. Artist: ‘J’. Welcome to Aboriginal Land Passport Ceremony, The Settlement, Gadigal Country (Sydney), 2012. Photo: Charandev Singh. Peaceful protests, Manus Island camp, Lombrum, November 2017. Photos published on the @ManusAlert Telegram Channel. 

Banner in memory of David Dungay, Gadigal Country (Sydney), 2018. Artwork by Simone Pash. Hands off Aboriginal kids protest, Naarm (Melbourne), 2016. Photo: Charandev Singh. Terror Island Wish You Were Here. Artwork: Ryan Presley. 

Black Lives Matter / Say Their Names Protest, Whadjuk Nyoongar Country (Perth), 2016. Photo: Marziya Mohammedali. Protest on Nauru, 2016. Some people who arrived on LEL boat were sent to Nauru, while others remained on Christmas Island and were eventually released into the Australian community, 2016. Artwork: Yousef, 10 year old child detained by Australia on Nauru. 

We acknowledge that this event took place on the land of the Gadigal people and we pay our respects to their Elders past, present and emerging.


The inquest findings into the death of Mohammad Nasim Najafi are now available.

In response, we have written a critique of the findings.

Dispatch: Inquest hearing into the Death of Mohammad Nasim Najafi
6th November 2018, Perth Central Law Courts, Courtroom 51
Dispatch by Michelle Bui

Action outside Coroner’s Court, Whadjuk Nyoongar Country (Perth), 2018. Photo: Ayman Qwaider.


‘Who killed my son? How did he die?…I want my son back.’ – Mohammad Nasim Najafi’s Mother


‘It is as if the entire world becomes against refugees. Yes! That is true. For refugees every situation is associated with pain and suffering.’ – Mohammad Nasim Najafi


Mohammad Nasim Najafi arrived in Australia seeking asylum in November 2012. Less than three years later he was dead. Six years after his arrival in Australia, the inquest into his death at the Yongah Hill Immigration Detention Centre was held in Perth. His inquest was the third into a death in custody at a WA detention centre in 2015 to be heard this year. The other inquests were for Fazel Chegeni Nejad a Faili Kurd whose body was found 50m from the perimeter fence of the Christmas Island Detention Centre and Ali Jaffari who died by self-immolation in his room in Eagle compound at Yongah Hill less than two months after Mr Najafi. Mr Najafi was a Hazara man from Hotqool in Afghanistan whose father had been killed by the Taliban when he was a teenager. He was about 27 years old at the time of his death and had been in detention for 1003 days. While his inquest hearing was listed for three days, it concluded on the first. No evidence was heard from anyone who had known Mr Najafi personally or been detained with him. The lawyer representing his mother was a watching brief and raised no questions throughout the proceedings.

The official response from DIBP following Mohammad Nasim Najafi’s death stated:

‘The department can confirm that a male detainee died at the Yongah Hill Immigration Detention Centre on Friday 31 July 2015. There was no indication of suicide or suspicious circumstances. The WA Police attended the centre and is conducting an investigation as per normal practices in such cases.’

At the time of Mr Najafi’s death it was largely unclear how he had died. This resulted in speculation from his friends and members of the broader community as they tried to make sense of his sudden death. The second sentence of the statement provided by the Department creates the impression that he died by natural causes and no other party is at fault. The way the statement is structured is intended to signal to the reader to move on; that there is nothing to see here. This statement reads very similarly to countless others that have been issued following deaths in detention. These statements are detached, formulaic and like a template that is constantly replicated and re-purposed. After attending three inquests within the space of 4 months, one cannot help but form the impression that the ‘normal practice’ is actually manufacturing death itself.

The first post-mortem examination conducted in the week following Mr Najafi’s death concluded that the cause of death was undetermined. It wasn’t until after further investigations were undertaken that his death was found in April 2016  to be consistent with an epileptic seizure. Mr Najafi had been diagnosed with epilepsy prior to his arrival in Australia when he was 21 years old. During the period preceding his death he was being prescribed two doses of 300mg of Carbamazapine per day (an anticonvulsant or anti-epileptic drug used to prevent and control seizures).  Neurologist Professor John Dunne, an expert witness, noted that 1 in 50 people will have epilepsy at some time in their life; however about 70% of people, when on consistent medication regimes, can get on with their lives safely as normal. Mr Najafi’s epilepsy was typically well managed, however a correlation was noted between his missing medication and experiencing seizures. In October 2014, after two years without a seizure, he experienced convulsions in a common room in the detention centre. Around the same time he had made a formal complaint about how medication was dispensed by IHMS.

When journalists questioned the Department as to why Mr Najafi remained in detention for such a prolonged period of time, they alluded to security issues. A report by the Commonwealth and Immigration Ombudsman confirms that Mr Najafi was the subject of an intelligence analysis; however it is unclear whether he understood that this was why he remained in immigration detention. It is unlikely that this was ever clearly communicated to him. Indeed, during the inquest it became apparent that on two occasions in 2013 Mr Najafi had expressed concern that he was being kept in detention for a long period because he was taking medication for epilepsy. Professor Dunne suggested that the perception that his ongoing detention was connected to his medical condition could carry a risk of under-reporting seizures.

31 July 2015: ‘If a person is dead in his bed, they would not know because they think he is asleep’

These words, conveyed to journalist Abdul Karim Hekmat by a friend of Mr Najafi’s who was detained with him, eerily foreshadow the evidence of the Serco officer who discovered Mr Najafi in his room. Around 6:30pm on the evening of 31 July, a Serco Detainee Services Officer (DSO) knocked, unlocked and entered Mr Najafi’s single room, S4 of Eagle Compound, to deliver a letter to him. He stated that when he entered the room, he saw Mr Najafi lying face-down on his bed and presumed he was sleeping. He said that Mr Najafi was known to have irregular sleeping habits so it was not unusual for him to be asleep at that time and decided not to disturb him and return later. Around 8:40pm he came back, turned on the light and saw Mr Najafi laying in the same position. He called out to Mr Najafi but there was no response. The DSO then ran his pen along the sole of Mr Najafi’s foot which was hanging off the edge of the bed, but still Mr Najafi did not respond. The DSO said he then shook Mr Najafi’s shoulder; however there was still no response. Mr Najafi’s body by this point was cold and stiff. An IHMS nurse later suggested that it appeared that rigor mortis had set in by the time the Serco officer and medical staff attended to Mr Najafi. At 9:10pm he was pronounced life extinct by St John’s paramedics.

Vigil for Nasim Najafi, Whadjuk Nyoongar Country (Perth), 2015. Photo: Marziya Mohammedali.

Failures in police investigation

A police investigator who gave evidence at the inquest described the situation at the detention centre on the night of 31 July 2015 as ‘tense’. He noted that riot police were called in that night to maintain order with the support of Serco Officers. He also indicated that the dog section was brought on site, but was not deployed. He suggested that video recording of the scene was not conducted by attending officers due to the ‘hostility of the detainees’. He characterised the situation as ‘volatile’, suggested there were threats to officers and that there was potential for civil unrest. Here he presented the narrative that officers did their best in trying conditions and that the detainees had a propensity for violence. No acknowledgement was ever made that in the event that someone – possibly a friend – dies while in the supposed care of the state, protest, distress and anger could be justifiable reactions. Following Fazel Chegeni Nejad’s death on Christmas Island there was a riot in the Christmas Island Detention Centre. In this case, undue emphasis was placed on property damage and reported violent conduct by detainees, while the extreme violence perpetrated against people detained in the centre – which culminated in the death of a person and incited the response of others – was not acknowledged. The criminalisation of witnesses and survivors is a recurring strategy used by the state and its agents following deaths in custody.

It was noted in a police report that a box of 24.5 of 100 Carbamazapine tablets were seized by police in their search of Nasim’s room; however, the police failed to properly document and photograph the box of medication. It remains unknown how Mr Najafi was able to access it when it is not IHMS practice to issue boxes of medication; indeed possession of medication other than in approved webster-paks is prohibited. An IHMS nurse confirmed that Carbamazapine is a drug that would only be used to manage epilepsy and would not be used recreationally as other types of drugs can be. While the nurse suggested audits of stock were regularly undertaken, the IHMS Area Medical Director provided evidence that he wasn’t aware of an audit of stock or medication around the time of Mr Najafi’s death and that there wouldn’t necessarily be a red flag raised if a box of Carbamazapine was missing, due to the nature of that drug. The origins of this medication and whether it had expired cannot be verified as a result of poor documentation by police. What is known is that Mr Najafi had low therapeutic levels of Carbamazapine in his system following his death which would indicate it was unlikely that he was substituting his missed doses for those tablets.

Failures of IHMS

Throughout the hearing, counsel for IHMS were the only party to raise any questions to the witnesses. It became clear quite quickly that part of the argument they were trying to establish was that Mr Najafi was largely compliant with his medication regime and therefore the processes that IHMS had in place for dispensing medication were adequate. She strenuously noted every occasion that Mr Najafi collected his medication in an attempt to minimise the significance of times where medication doses were missed. Mr Najafi was known to have a sleeping disorder which meant he had very irregular sleeping patterns and often slept throughout the day and remained awake throughout the night. While Professor Dunne recognised the difficulties that someone with a sleeping disorder may have in attending medication rounds twice per day, counsel for IHMS refused to accept that this might be the case. They suggested that the record of Mr Najafi collecting medication the majority of the time suggested that he managed to do so without difficulty. This is not withstanding Professor Dunne’s assessment that people diagnosed with epilepsy are generally very compliant and committed to their medication regime and recognise the importance of taking their medication, particularly after experiencing seizures. It seems quite clear that Mr Najafi was committed to taking his medication, however his sleep disorder and the rigid and inflexible dispensation processes of IHMS made this difficult for him.

An IHMS nurse who gave evidence stated that in his view, the only type medication you can get away with missing doses of is pain medication, as pain can be independently managed by the client. He stated that as a nurse, any other missed medication would be concerning. Despite this, no one who worked for IHMS appears to have made any effort to follow up or ensure that Mr Najafi received the doses of medication that he required during the week preceding his death.

At the time of Mr Najafi’s death there were three medication rounds per day: between 8-10am, 12-2pm and 7-9pm. The IHMS medical clinic was open 9am-5pm on weekdays with after-hours medical assistance accessible through Serco who could contact a Health Advice Service (HAS) telephone line administered by IHMS. One of the IHMS nurses noted that they previously provided a 24/7 service but at some point down the line the process changed; he expressed criticism of the change and suggested it made it more difficult for both IHMS and Serco staff. FOI documents indicate that after- hours onsite staffing ‘was largely removed under the latest contract to better accord with Australian community health standards and to meet Government expenditure targets. This reduction has been criticised by scrutineers such as the Ombudsman and the Department is monitoring’. On the night of Mr Najafi’s death, the IHMS Nurse opted to attend to the Code Blue that was called instead of continuing the medication round.

For those who were eligible to have their medication dispensed in 7-day webster-paks, there was a period between 8:00am and 3pm on Fridays during which they needed to collect them. While Mr Najafi often collected his webster-paks, there were several occasions where he attended a day late. Six days before Mr Najafi’s death he attended on the Saturday to collect his webster-pak and IHMS staff refused to issue it to him and advised that he had to attend twice daily for the next week to collect his medication. This raises the question of whether he would have had a fatal seizure on 31 July if he had access to a webster-pak and had regularly been taking his medication throughout the week.

‘On 16/05/15 at appointment primary health nurse explained if he does not present for weekly webster, he will be denied this privilege’ – note made by nurse

Professor Dunne was critical of the expectation that Mr Najafi would collect medication twice daily and that a webster-pak was considered a ‘privilege’. He suggested that to expect someone with a sleeping disorder to present twice daily for medication was ‘not a practical or reliable alternative’ to providing a weekly supply. The Area Medical Director for IHMS (who at the time oversaw the west region but currently oversees the east coast and offshore sites) responded defensively, stating that Mr Najafi seemed to be quite compliant most of the time, and that he did not agree with Professor Dunne’s assessment that it wasn’t a practical option. The punitive approach that IHMS took to dispensing medication to Mr Najafi is a reflection of the kinds of lethal practices that are implemented to manage bodies that are viewed as non-compliant. The seemingly trivial denial of a webster-pak arguably contributed to his seizure and subsequent death.

Evidence was heard that following Nasim Najafi’s death IHMS has implemented a process to trigger follow-ups of people who do not present to receive essential medication, arising out of a recommendation from an ABF report. Despite this, counsel for IHMS appeared to be trying to argue that there was nothing wrong with the process or lack thereof that IHMS had in place to begin with. While the IHMS Area Medical Director initially suggested there were some lessons for IHMS following the death, when questioned in respect to a statement made by Professor Dunne who said words to the effect of ‘the fact that there was no apparent process in place to ensure essential medications were dispersed was not satisfactory or reasonable care’, he seemed to back away from this and responded that he did have access to medication rounds and attended some of those rounds.

While Mr Najafi had not been diagnosed with any chronic or acute mental health issues, it was noted that news of ongoing killings in Afghanistan and his long-term detention sometimes lowered his mood. He was also known to sometimes suffer from headaches. Professor Dunne was of the view that Mr Najafi’s missing medication should have been a red flag for IHMS and should have triggered a review or assessment of his wellbeing, given that it was out of character. Professor Dunne speculated as to whether irregular attendance to collect medication in the 6 days preceding his death could have been a sign of Mr Najafi’s having given up. In any case he was of the view that IHMS should have attempted to engage with him during this period.

Notably, just weeks before Mr Najafi’s death he reported an assault. Following this report of an assault, which was not discussed in detail during the inquest, he was moved from Hawk Compound to a single observation room in Eagle compound, supposedly for his own safety and security. It was heard that his room was in close proximity to the officers’ station. It is unclear why he was moved as opposed to the alleged perpetrator and whether he was supposed to be subject to any routine watches or checks.

Unnatural Deaths: onshore/offshore

Mr Najafi is not the only man to have died within Australia’s immigration detention system who was affected by epilepsy. Faysal Ishak Ahmed and Salim Kyawning both died while forcibly confined on Manus Island and were reported to be grappling with similar health issues. Faysal Ishak Ahmed was a young Sudanese refugee who died in December 2016 after suffering a seizure and collapsing inside the Manus Island Detention Centre. It was reported that when he fell, he hit his head. He was subsequently flown to Brisbane for medical treatment but died a couple of days later. He had suffered numerous blackouts and collapses over the months preceding his death and repeatedly sought medical assistance.

‘Faysal became unconscious and collapsed over and over again but every time he visited the medical centre the doctor would tell him he was fine. On every occasion he returned empty handed and angry.‘ – Walid

Protest at Border Force following Salim Kyawning’s death, Naarm (Melbourne), 2017. Photo: Charandev Singh.

Salim Kyawning was a Rohingya refugee in his 50s who had frequent seizures. He was reported to suffer from temporal lobe epilepsy that was poorly controlled. Salim Kyawning suicided in May 2018 after struggling to receive support for physical and mental health issues.

‘Salim would at times fall to the ground and begin to tremble. His mouth would foam and he would yell. All the refugees were familiar with his situation. All the staff working in Manus prison, the medical personnel, everyone in the immigration department including the immigration minister, human rights organisations, and the journalists reporting about Manus, they all knew about Salim.

…Like Faysal, Salim was struggling to stay alive. He approached me, indicating to his heart, to his head, trying to tell me that he was afraid he would end up like Faysal.

…Salim had epilepsy. Two years ago immigration decided to transfer him to Australia for treatment. He stayed in Darwin for a while but they exiled him back to Manus while he was still experiencing a great deal of suffering.’  Behrouz Boochani

The deaths of Mohammad Nasim Najafi and Faysal Ishak Ahmed may be viewed by the courts as ‘natural deaths’. Discussions around them are largely medicalised; however it is necessary to avoid the conclusion that these men were going to die regardless of whether they were contained by the detention system or not. These deaths are anything but natural. Dying within detention centre walls is not natural. When someone’s liberty is taken away, and they have no choice in what medical practitioners and other support they can access, those involved in this process owe them a higher duty of care. As Professor Dunne noted, when somebody is in a place of detention, service providers have a responsibility to ensure that medication is dispensed and provided. Until the system of mandatory detention is dismantled, however, deaths and associated inquests will continue.

These inquests of course will examine the minute details surrounding an individual case but fail to place each case in context and acknowledge the intended consequences of detention.

 Final Words

At the conclusion of the inquest hearing the Coroner noted that from her perspective the main issues were the issuing of webster-paks, the ‘red herring’ that was the box of medication and whether there was a causal connection between the missed medication and the seizure. She stated that it was a ‘sad case’ and it largely seemed that Mr Najafi’s death could have been prevented if he was taking the required medication– though due to the unpredictability of seizures it was not necessarily entirely so. She noted, as she did in the case of Fazel Chegeni Nejad, who died 54 days after being transferred to the detention centre on Christmas Island, that she would look at his history, but that his prolonged detention was not the focus of her inquest. She noted that it was reassuring that changes had since been made to IMHS procedure to ensure there was some follow-up of people who were required to take essential medication. This brought my mind to a poem that Mr Najafi had shared on Facebook prior to his death, a translation of which reads:

‘There is not enough time, it might be too late when one realises…. But we still don’t believe the reality…. It might be too late when you come to see me…You will not have any other option but to cry at my grave and say that this was the destiny……(Please pray for me dears)’

It was too late when authorities came to see Mr Najafi. It was also too late when IHMS were compelled to change their procedures. Mr Najafi’s community buried him and cried at his grave. Mr Najafi’s mother cried, but cannot visit the grave of her eldest son, who was laid to rest in foreign and unwelcoming soil. In reflecting on Mr Najafi’s words, I consider that if it was his destiny to die, this destiny was one determined by those responsible for his care, who detained him upon his arrival in Australia and refused to fulfil their duty of care to him and ensure that reasonable measures were taken to keep him safe.


The inquest findings into the death of Ali Jaffari are now available.

In response, we have written a critique of the findings.



Dispatch: Inquest Hearing into the Death of Ali Jaffari
9th and 10th, Perth Central Law Courts, Courtroom 51
Dispatch by Michelle Bui
Content warning: explicit references to suicide and self-harm.


‘Life-vests’, 2016-17. Artwork: Ben Quilty.


The inquest hearing into the death in custody of Ali Jaffari at the Yongah Hill Immigration Detention Centre (IDC) was listed for three days from the 9-11 October 2018. The first day coincided with the anniversary of Jaffari’s arrival and detention in Australia on 9 October 2010. The day of arrival would have been one of anticipation and hope to build a new life in Australia. Nothing could have predicted that 8 years later lawyers would gather in a courtroom in Perth – a city he’d probably never heard of when he left his homeland – to discuss the circumstances surrounding his painful death. The inquest concluded on the second day, leaving the few members of the public who were present with an overwhelming feeling that it had concluded prematurely and that the hearing was inadequate and incomplete. This feeling pervaded the inquest, from the shallow examination of witnesses to the absence of a representative in court who would endeavour to seek answers and accountability on behalf of Ali Jaffari. This role is usually played by representatives of the family; however the only parties represented in this inquest were Serco, International Health and Medical Services (IHMS) and the Department of Home Affairs – each of whom only sought to defend their own interests and avoid any potential for adverse findings against their clients. To the observers from the Deathscapes team the whole exercise felt like a macabre performance of the legal system. Legal representatives went through the motions prescribed by the court in order to tick the box corresponding to a completed inquest. The content was circumscribed by very narrow parameters of the inquiry, and by the end of the performance it seemed that more questions were raised in our minds than were answered. The fundamental issue of how Ali Jaffari was actually able to set himself alight while in the custody of Serco and the Department of Home Affairs remains unsolved.

Ali Jaffari’s story cannot be framed within the narrative of a ‘good’ or ‘deserving’ refugee. His death elicited little public sympathy and news headlines largely created the impression that his death was justified. He had previously received media attention after being convicted in the Victorian County Court of an indecent act with a child. He was given a community corrections order and placed on the sex offenders register for 15 years. In May 2014 he was arrested and charged with accessing child pornography on his laptop at the St Kilda public library. This was a breach of the community corrections order he had been given. His permanent protection visa was cancelled under section 501 of the Migration Act and he was re-detained.

At the inquest opening, Counsel Assisting the Coroner noted that the focus of this inquest would be on the supervision, treatment and care that Ali Jaffari received. This raises the question, how much care does a man like Ali Jaffari deserve as someone on the extreme margins of society, who had previous criminal convictions and who was considered by the majority of witnesses to be ‘odd’, ‘weird’, ‘creepy’, ‘racist’, ‘anti-social’ and ultimately not really human? If the lives of refugees are already considered as disposable where does that leave people like Ali Jaffari who are not perceived to have any redeeming qualities that could make them worthy of personhood let alone justice?

Indeed as was also evident during Fazel Chegeni Nejad’s inquest hearing, Ali Jaffari was largely reduced to ‘the detainee’; language that is mandated by Serco and the Department to describe the people whom they incarcerate. During this inquest there was an even greater sense of absence in the courtroom than at the inquest for Fazel Chegeni Nejad: the absence of family and of community whose presence could have challenged the narrative that his life didn’t matter. On both days witnesses to the inquest included members of the Deathscapes team and two refugee rights supporters. On the first day a lone journalist also sat in to bear witness. The public record of this inquest to date, is this dispatch and a single article published by the ABC. Refugees who die in Australia often do not have family members here to seek justice on their behalf, it is in light of this and the other barriers to attending inquests that members of the wider community might face that we feel it is particularly important to document and bear witness to these proceedings.

The weaponisation of mental health: a pattern of harm

In the month or so preceding his death, Ali Jaffari made several self-harm/suicide attempts. Dr Janca, a visiting psychiatrist contracted by IHMS, explained his understanding of Ali Jaffari’s suicide attempts as a ‘reaction to prolonged detention and his frustration with his unresolved immigration status’. He insisted that Ali Jaffari did not have a serious mental illness –however other witnesses indicated that they had been advised that he had ongoing mental health issues for which he was prescribed medication. One witness noted the extreme difference in his disposition when he was adhering to the prescribed medication regimes and when he was not.

Dr Janca maintained that he did not believe in-patient treatment at a mental health ward or psychiatric facility would have been appropriate. He expressed the view that the standard of care Ali Jaffari received in detention was good, and that being admitted to a psychiatric ward wouldn’t have provided him with any further treatment. This is interesting to consider in the context that Ali Jaffari’s suicide attempts were considered by the doctor himself as, in part at least, a response to his detention. This raises the question of what might have been the benefits of removing him from this environment, perhaps to an in-care environment where he would have received treatment for the offending behaviour for which he had been convicted.

It remains unclear the nature and extent of whether Ali Jaffari was able to access any rehabilitative programs to address the pattern of offending that had led to his visa cancellation. After his first conviction following an incident in 2013 he was reportedly placed on a community corrections order which included participation in a sex offenders program. Only 3 months into this order he was redetained and therefore had no access to any programs after that point. Whether his offending could be linked to a mental disorder or underlying mental illness also remains unknown. The first Ombudsman report tabled in Parliament notes that at the time he was redetained IHMS reported that he was assessed as having suspected mental health issues.

The second Ombudsman’s report, tabled in Parliament after Ali Jaffari’s death, indicates that in June 2015 he was being prescribed antipsychotic medication. From 21-28 August he was transferred to hospital after self-harming by cutting his throat, an injury that required surgery. On 9 September he was taken off Supportive Monitoring and Engagement (SME) observations after reporting that he was feeling well and had no further intention of harming himself. Just days later, however, on 11 September, he was again transferred to hospital after reopening his neck wound. He was discharged the following day and on 14 September he saw Dr Janca, following which his SME observations were downgraded from ‘high imminent’ to ‘moderate’. According to Serco guidelines, a ‘moderate’ SME rating still requires observations at least once every 30 minutes, however whether these observations were undertaken was not clarified during the inquest hearing. Just hours before his self immolation he again denied thoughts of suicide and was noted to be in a good mood. Here a pattern emerges where acts of self-harm correlate with a reported improvement in his mood.

Dr Janca characterised Ali Jaffari’s self-immolation as a form of ‘impulsive/demonstrative protest’. While a single act considered in isolation could be characterised as reactive or ‘impulsive’ in nature, in the weeks prior to Ali Jaffari’s suicide there emerged a pattern of self-harming which could be described as a pattern of serious self-harming and attempted suicide. It is in the context of repeated self-harm and suicide attempts which required hospitalisation that his final self-immolation – perhaps an escalation of previous attempts – took place.

While it was suggested that Ali Jaffari had access to several mental health professionals, Dr Janca was the only medical witness to provide evidence at the inquest hearing. This is despite the fact that he was reviewed by IHMS staff just hours before his self-immolation. The absence of any critical questioning of Dr Janca by Counsel assisting or by the Coroner himself reinforces our impression of a cursory and rushed inquest process for a life deemed unworthy in every respect.

Section 501, indefinite detention and the impetus to self-deport

At the time of his death, Ali Jaffari was confronted with three options: indefinite detention, self-deportation or death. His permanent protection visa had been cancelled under section 501 of the Migration Act and he had no realistic chance of having his visa reinstated. As a Hazara born in the Ghazni Province of Afghanistan, if he was compelled to self-deport, he would have been returned there despite the fact that his surviving family members now live in Pakistan as refugees. Two witnesses during the Inquest hearing – Dr Janca and a former Serco Welfare Officer who is now employed by the Department of Home Affairs – suggested that Ali Jaffari appeared to be at peace with a decision to ‘voluntarily’ return home. Dr Janca expressed that he thought Ali Jaffari’s immigration status had been decided and that he had signed a letter of agreement to be deported or returned home. He said he had the impression that he was looking forward to being out of Yongah Hill. The former Welfare Officer at the centre echoed this opinion when she said Ali Jaffari had met with the Ombudsman and his lawyer and decided he wanted to check if he was eligible for post-return support to go home. She said he seemed happy and sure of his decision.

A summary made by the Ombudsman raises questions around what decision Ali Jaffari ultimately made. It indicates that at the beginning of September he had changed his mind about what course of action to take.

After Ombudsman staff explained to Mr X that the Ombudsman’s office could not organise legal representation for him, he stated that he would have to return to Country A. He said that his family had told him he could not return but he said he did not think he had any other option. He requested assistance to contact the International Organization for Migration to organise his return to Country A and asked that his case manager be advised that he wanted to complete the paperwork to return voluntarily.

Shortly after the interview finished, Mr X advised that he had changed his mind and that he could not return to Country A because he feared for his life. This information was conveyed to his case manager.

The contrast between the opinions presented by witnesses and the information documented by the Ombudsman suggest that Ali Jaffari was conflicted about what decision to make. In any case, the options provided to him by the Department – to either ‘voluntarily’ go home or remain in detention indefinitely – were ultimately ones that he could not accept.

The fire and eliminating accountability

One of the issues considered during the inquest hearing was the smoke alarm in Room 1B of the Eagle Compound (Ali Jaffari’s room) which had been disabled and appeared not to be working on the night that Ali Jaffari self-immolated. Counsel for Serco on multiple occasions questioned witnesses about ‘fabric checks’ conducted by Serco Officers, emphasizing that Serco had fulfilled their obligation by conducting routine maintenance checks of the alarms. Each witness was also questioned in respect to the frequency of uncovering and confiscating contraband lighters in the centre. The overarching issue of Serco’s complicity in detention arrangements that are inherently harmful was of course not confronted.

When one witness mentioned the fact that contraband lighters are much more commonly found in Yongah Hill now than they were three years ago, Counsel for Serco was very quick to raise on objection. Coroner King indicated that he understood the objection, but found this information interesting to hear. Despite this, the line of questioning was not taken further. This was the only objection raised in the entire inquest and also one of the few times where the period beyond 15 September 2015 was given even the briefest of considerations. It struck me that the availability of lighters in the centre now would be very relevant in terms of the Coroner’s prevention role and particularly given the recent fires that engulfed  the Falcon compound at Yongah Hill IDC just a month prior to the inquest, following the hospitalisation of Saruuan Aljhelie who died days later as a result of a suicide attempt.

The trauma of bearing witness

The first witness on Day 2 was an Egyptian man who had been detained at Yongah Hill in September 2015. He did not know Ali Jaffari personally although had seen him before as he was assigned the neighbouring room. In his evidence, he described being in his room watching TV when he heard a smoke alarm go off. He went outside and soon became aware that someone had set themselves on fire in the adjacent room. He described going into the room and witnessing a Serco officer entering and opening the bathroom door which had been locked. He said that he saw Ali Jaffari on the floor of the bathroom and that at that point he was still on fire. He was asked to leave the room but described how over the subsequent weeks he could not sleep, and every time he went to the bathroom in his own room (a replica of Jaffari’s) he imagined seeing Jaffari there. It was only this witness who spoke of how he was psychologically haunted by what he had seen that night. He mentioned that he had spoken to a psychologist about his experience, but there was no indication of the extent of his engagement with mental health or trauma specialists in the following days and weeks. There was no scope for questioning whether a protocol exists for counselling fellow-inmates in cases of deaths in custody, and if so to what extent any such protocol was followed in this instance. There was no indication of how long the witness was forced to stay in what could only be characterised as an incredibly traumatic environment. Anecdotally, in respect to deaths in immigration detention, particularly the recent death of Saruuan Aljhelie at Yongah Hill, people have noted the absence of any substantial post-suicide support. Business continues as usual while witnesses are left struggling to make sense of what they experienced in an environment that denies the conditions necessary for recovery and healing.

The monolingual order of the legal system

After recently sitting through the inquest into the death of Fazel Chegeni Nejad on Christmas Island in the same year, we could not help but draw comparisons between the two inquest hearings. The treatment of witnesses who remain in detention seemed consistent. As noted in our Dispatch 6 on the inquest into Fazel Chegeni Nejad’s death, the legal machinery is deeply monolingual.  Those unable to read English, do not have access to the same basic rights afforded to English speakers, such as access to original statements. Transcripts of their original statements are not provided to them, nor are they given time to arrange for their own translations.

Another witness who remains in detention, a fellow Hazara, who was the last person to see Ali Jaffari before his self-immolation, said he did not know much about him. He just knew that he was ‘upset and disappointed, very disappointed’. He also disclosed in his original statement and reiterated in his oral evidence that following Ali Jaffari’s second self harm attempt, a Serco officer asked him why the witness had moved compounds and didn’t look after Jaffari or care for him. This description sounds like an attempt by Serco officials to unfairly displace blame and place responsibility on someone who was struggling to deal with their own issues at the time.

The End

The inquest hearing ended almost abruptly with the declaration by the Coroner outlining the process that could be expected following the conclusion of the hearing. He stated to counsel that from his perspective he did not require submissions from them and affirmed that he had no intention of making any adverse findings. To return to the question of how much care someone like Ali Jaffari is deserves, I believe there are inferences that can be drawn from the conduct of this inquest.

At the beginning of the inquest, one of the police detectives casually noted that she could not recall if she herself had attended the room where Ali Jaffari died as she had been to Yongah Hill IDC on a number of occasions, including for other deaths. This suggests that responding to deaths at the centre was not necessarily remarkable or exceptional for police. Each of the Serco witnesses who were called to provide evidence continue to be employed at Yongah Hill or with the Department of Immigration. The witnesses currently employed by Serco all gave their evidence via video link from Yongah Hill; many have been working in the system for 5 years or more. While some of their descriptions of what happened on the night of 15 September were very graphic, it was as if they’d been instructed not to explicitly name or acknowledge what happened as a self-immolation. Their ongoing employment suggests that for some workers removing a burnt, ‘corpse-like’ body from a detention centre room evidently wasn’t enough reason to cease employment at the centre.

Three years on, the last person to see Ali Jaffari before his self-immolation remains in immigration detention, now at Villawood in Sydney, with no resolution of his status or indication of when he will see freedom. The emotional conclusion to his evidence disrupted the ordered and detached process of the court. He implored the court to hear that no one is helping him and that he is ‘suffering a lot’. He emphasised that he cannot go back to his country despite being asked to return many times and repeated how, when his mother calls him, he cannot speak, but only cry. When asked about the pressure that Ali Jaffari was experiencing prior to his death, he suggested to the courtroom ‘Maybe the same pressure that is on me, was on him?’

Again, the court provided no answer or gave any indication of having heard the implicit appeal in this question.

The Recent Derbal Yerrigan Drownings and “Aboriginal Deaths-in-Custody”

Dr Carl Hughes

MB BS   B(Med)Sc   Cert Diving Med (R.A.N.)

WARNING: Aboriginal and Torres Strait Islander readers are advised that this article contains details of deceased persons.

A tree in a public park is adorned with an Aboriginal flag. Flowers, balloons and photo frames are laid around the tree.

Memorial for JackJack and Chris, Derbal Yerrigan, 2018. Photo: Michelle Bui.

The local Noongar Community in Perth is still grieving over the recent, tragic deaths of two Aboriginal teenagers (Trisjack Simpson and Christopher Drage, aged 17 and 16 years) who lost their lives in the cold waters of the Derbal Yerrigan (Swan River).

The media has reported that the boys drowned as they attempted to ‘dive and swim away’ from local police.

The boys’ deaths are being treated as “deaths in police presence” and the Office of the W.A. Coroner will conduct an inquiry into the full circumstances of the drownings.

The W.A. Police Commissioner, Chris Dawson advised:

“(The) two boys are believed to have got into difficulties in the middle of the river… and (then) succumbed to the conditions…. and were not seen to resurface…this is nothing short of a tragedy”

Commissioner Dawson added: “I offer my condolences to the families of the two boys.”


This is not the first time that a young Aboriginal has drowned in similar circumstances.

In Dubbo in 2003, another Aboriginal youth (known as R.S.), drowned in the nearby local Wambool river (Macquarie River). R.S. drowned near a well-known local bridge, named in honour of a famous Dubbo Aboriginal citizen, Tracker Reilley.

In similar, tragic circumstances to the Derbal Yerrigan drownings, R.S. was observed by Dubbo Police near the ‘traditional’ Macquarie River. In other words, R.S. was now close to the local river “in the presence of police.”

For those with experience of the historical consequences for an Aboriginal person being “followed”, or “pursued”, by police in such circumstances, the “Red Danger” warning lights would have been flashing and the bells would have been clanging.

For R.S., this was now an extremely dangerous situation.

Letter by Robin Sheiner to The West Australian Newspaper, it reads 'Dear Sir, I am distressed to read the commentary around the recent drownings of the two Aboriginal teenagers 'in police presence'. For me, it is reminiscent of the drownings of many Aborigines that occurred at the Murray River in WA when a phalanx of soldiers on the 25th October 1834, was deployed specifically to 'punish the [A]borigines.' Here I quote from the original log book of my ancestor, John Septimus Roe, who was in the punitive party as the Surveyor General at the time. "On meeting with an [A]boriginal tribe at 'the Great River'", my ancestor writes in his journal, "the ten mounted soliders among the party, rifles loaded, fired upon the [A]borigines who had leapt into the river. No men of the tribe survived and eight women only who, with their children, watched in silence as their men were killed." The question becomes how far, as a society, have we advanced in our attitudes to Aboriginal people? Do we think, as the dominant population of white people, that our lives are of more value? Also, a simple question, why does my Aboriginal grandson and his friends, intelligent, law-abiding and university educated, get taken aside and searched when they enter shops? The final question - why did the 5 young teenagers run from the police? Had they imbibed, unsurprisingly, their own history of police confrontation and Aboriginal youth incarceration numbers? Yours faithfully, Robin Sheiner. (The author has given Deathscapes permission to publish this letter, which was originally sent to the West Australian newspaper. The letter was not published by the West.'

Dr Hannah McGlade speaks at the John Pat memerial, which can be seen to the left of the frame. Native flowers are laid around the memorial. A building in the old Fremantle prison complex can be seen in the background.

Hannah McGlade discusses Robin Sheiner’s letter at the annual remembrance ceremony for John Pat at Fremantle jail, 23 September 2018.  


From a physiological point of view, a cold, free-flowing, freshwater river is a very hazardous environment, even for a strong, fit swimmer.

Royal Australian Navy Clearance Divers are arguably some of the fittest athletes in any Navy. (Under combat conditions, they train to remove explosive mines from ships.) Clearance Divers accept that they cannot swim against a current of about 2.5 knots (approximately ‘walking pace’) for any length of time. Therefore, attempting to swim against a moderate current (say about 3-4 knots) is almost an impossible feat. When a low water temperature (say about 10 degrees Celsius, as in both the Swan and Macquarie River cases) is added to the situation, the danger of hypothermia and drowning increases considerably. The chance of a swimmer drowning in such a river is now very real.


As reported in The Guardian (Australia) “Deaths Inside” database, two other drowning deaths are recorded where the Aboriginal person involved was “trying to flee the police”.

In 2012, a 37-year old Aboriginal man reportedly drowned in the Djarlgarra (Canning River at Thornlie, W.A.). He attempted to evade police. It is believed that he jumped into the Djarlgarra as he tried to flee from police. (His body was not recovered until 7 days later.)

In 2013, a 40-year old Aboriginal man reportedly drowned as he attempted “to evade police” by swimming across the Millewa (Murray River, downstream of Berri, South Australia).

It is reported that neither the 37-year old, nor the 40-year old, were charged with any crime.

Flowers have been laid at the banks of the Derbal Yerrigan. People gather by the river can be seen to the left of the frame. Apartment buildings that overlook the river can be seen in the background along with trees and bushes that line the rivers' edge.

Memorial for JackJack and Chris, Derbal Yerrigan, 2018. Photo: Michelle Bui.


It is worth considering the real dangers for Aboriginals when they are being “pursued” or “followed” by police.

Many Aboriginal families have expressed their great anxiety when they are informed that their son, or daughter, is being “pursued” by police (for any reason). It is well known that Aboriginal youths tend to panic in the presence of police.

Whether the youth is ‘justified’ in his/her panic state, the fact is that many do panic.

A possible reason for panic is the fact that most Aboriginal families are aware that a family member (perhaps a distant relative) is likely to have experienced contact with the Juvenile, or Adult, Justice System, or even possibly a family Death in Custody.

Whatever the reason, a panic reaction (usually out of all proportion to any alleged charge) is quite common.

T.J. Hickey and Redfern (February 2004)

Perhaps the most well-known, recent Aboriginal death in custody which involved police “pursuing”, or “following”, an Aboriginal youth is the case of the death of T.J. Hickey, aged 17 years, in Redfern in February 2004.

T.J. had dealings with the Walgett Children’s Court and probably knew that there was an Apprehension Warrant in existence when he became aware that police were “following” him, as he cycled along the streets of Redfern.

Although there is still some controversy concerning the exact mechanism of T.J.’s death, it is known that he was “peddling very fast” as two Redfern Police vans “followed” him through the streets and lanes of Redfern.

T.J. may have “panicked” seconds before his death.

What is clear is that his body was propelled over the handlebars of his bicycle and that he became impaled onto the steel bars of a fence at the rear of a Tower building in Waterloo. T.J. was impaled by the neck on the steel bars.

As police walked towards him, he was still impaled on the fence. He cried out:

“I want my Mum… I don’t want to die !!”

A child rides a bicycle, he turns toward the camera and holds up a photo of TJ Hickey that obscures his face. Justice for T.J Hickey Rally, Gadigal Country, 2018. Photo: Charandev Singh.


What does the Royal Commission into Aboriginal Deaths in Custody have to say about Aboriginal Youths and the Justice System ?

Unfortunately, the observations and Recommendations of the Commission are as relevant today as they were at the time they were written by the Learned Commissioners:

  • Aboriginal youths are incarcerated at higher rates than non-Aboriginals
  • Alternatives to detention should be actively implemented a.s.a.p.

The relative dangers of a “Police Pursuit”

The dangers of:

  • a “police pursuit” or
  • “a (close) police presence”

need to be weighed against the danger of harm (or death) of the youth(s).

I feel sure that the Royal Commissioners would urge police to adopt a position of “great caution in their operations.”

As discussed above, there are very real physiological dangers of hypothermia and drowning where a “scared” and “panicking” Aboriginal youth is in close proximity to a free-flowing, cold, fresh-water river.

Without doubt, consideration should be given to an early “calling off” any chase, or pursuit, of Aboriginal youths in such circumstances.

Additional Police Operational Training seems to be required urgently.


Dr Carl Hughes is a forensic pathologist who worked closely on a number deaths in custody inquests with the late Uncle Ray Jackson and the Indigenous Social Justice Association. Read detailed bio here.

Repetitions of violence: on David Dungay’s and Fazel Chegeni Nejad’s inquests

A close up photo of a banner held outside the Perth Coroner's Court. It reads 'Killed by the System. End Mandatory Detention!' on the left side and on the right is a drawing of a paper crane with the words 'We remember Fazel Chegeni'.

Over the last month, the Deathscapes project, for which both authors work as Chief Investigators, has produced daily dispatches from two successive inquests into racialised deaths in custody. The first of these was into the death in custody of 26-year-old Dunghutti man David Dungay, in Long Bay gaol, held in Sydney from 16-27 July. The second, held in Perth from 30 July-10 August, investigated the death of the Kurdish refugee Fazel Chegeni Nejad, aged 34, held in custody at the North West Point Immigration Detention Centre on Christmas Island.

In this article, written in the days immediately following the inquests, we explore the object lessons offered by the inquests for Mr Dungay and Mr Chegeni Nejad. We detail the routine operations of epistemic violence, and the disjunctions between the process and its violent and troubling effects, that became evident to us on several levels.

Read article ‘Repetitions of violence: on David Dungay’s and Fazel Chegeni Nejad’s inquests‘ by Suvendrini Perera and Joseph Pugliese published in Overland

A series of dispatches from the coronial inquest currently underway in Perth for Mr Fazel Chegeni Nejad.

Dispatches by Michelle Bui and Suvendrini Perera
Photos by Michelle Bui unless otherwise noted

Small coloured paper cranes line a low wall. The cranes are reflected in a glass pane behind the wall. The ledge is wet from rain earlier in the morning.

Fazel used to spend countless hours folding paper cranes for the happiness of others, which his visitors would then take to people in hospital, aged and hospice care on his behalf. Following Fazel’s death, people in detention and in the community folded paper cranes to honour his memory. (RRAN media release)


Inquest into the Death of Fazel Chegeni Nejad

Perth, Central Law Courts, Courtroom 51

A group of people gather outside the Perth Coroner's court. They hold banners that read 'Killed by the System, End Mandatory Detention!' and 'Stop Deaths by Policy'. Paper cranes line the pavement in front of them.Supporters gather outside the Coroner’s Court.

Day 10: August 10, 2018, speech made by Michelle Bui at closing action

A group of supporters gather again outside the court at the conclusion of the inquest hearing. Men and women hold placards with Fazel's photo on them, along with banners.

Action to mark the closing of the inquest of Fazel Chegeni Nejad.

‘I’d first like to acknowledge that we gather here today outside of this court on the land of the Whadjuk Nyoongar people and pay our respects to Elders past, present and future. Sovereignty was never ceded and this always was, always will be Aboriginal land. As we gather today to call for an end to mandatory detention and deaths in immigration detention, we also call for an end to deaths in police and prison custody, acknowledging that too often the victims of deaths in custody are First Nations people who are grossly over-represented in the prison system. We don’t want to keep gathering outside of this court, we want to see an end to people dying while in the so-called ‘care’ of the state.

Importantly I’d like to acknowledge the man who we are here for today, Fazel Chegeni Nejad, along with his family who lost a son almost 3 years ago on Christmas Island, thousands of kilometres away from their homeland in Ilam. Fazel, a Faili Kurd who had a known history of torture and trauma, sought safety and freedom in Australia in 2011 but was denied both. I can only imagine how crushing and incomprehensible it would have been for his family to learn that Fazel’s body had been found about 50m outside of a prison fence on a remote island, in a country that was hoped to provide him with refuge.

I’d also like to acknowledge Fazel’s friends who knew him in detention, some of whom, despite facing potential personal consequences were determined to give evidence in this inquest for their friend. I know for some this was not easily done and took a great deal of courage to revisit a period that was a source of such intense grief and distress. As we gather here today, some of his friends are going about their lives in the community, while others who were detained with him in 2015 remain in detention, broken hearted at the loss of their friend and still yearning for freedom.

While I did not personally know Fazel, as details of his time in detention have been revealed over the past two weeks I’ve seen traces of him in people I do know who have been subjected to the same punitive systems and regimes. Many of these people are yet to find safety and security, I fear some are at risk of a future similar to Fazel’s. One of the men who came to my mind, has been in detention for over five years, and is currently on hunger strike. At the beginning of this week, he message me in the early hours of the morning to say that they were taking him to Villawood. Sudden transfers like this are routine and mean that those with friends or family in the community are never afforded a chance to properly say goodbye.

A paper crane pinned to a jacket.

Paper crane worn in court on Day 10 of Fazel Chegeni Nejad’s Coronial Inquest.

Fazel Chegeni Nejad was incarcerated in immigration detention for 1477 days at the time of his death. The last 54 of those days were on Christmas Island, the most geographically isolated centre in Australia. The detention centre on Christmas Island is a high security centre akin to a prison. While some witnesses during this Inquest denied that it was used to punish people, one conceded that at the time it was used to ‘deter’ bad behaviour and to send a message that it wouldn’t be tolerated by the Commonwealth. Christmas Island has gained a reputation for being highly restrictive and punitive and at times has been likened to Guantanamo prison.

Like most people, who’ve been in detention long term, Fazel’s body traversed several state borders but not under his own discretion. He was bounced around the system averaging two transfers per year. He saw a glimpse of freedom when he was granted community detention in Melbourne, however that was taken away following a conviction for an incident 2 years prior at Curtin IDC. This conviction was made in the same building that Fazel’s death has been investigated. The sentence was later overturned and described as ‘manifestly excessive’ however despite this, Fazel remained in closed detention until the time of his death.

In 2015, Fazel Chegeni Nejad was one of at least 9 people to die while subject to Australia’s immigration policies, either while in custody or in the community. Since his death, more than 15 people have died in detention onshore, offshore and in the community. We believe many of these deaths can be viewed as deaths by policy; as a product of the punitive measures put in place to ‘deter’ and punish those who seek safety in Australia. A Coroner recently ruled in Brisbane that the death of Hamid Khazaei on Manus Island was ‘preventable’ we believe this could be said of many of border related deaths in Australia.

A photo taken behind Professor Suvendrini Perera shows her addressing the crowd gathered outside the court, who hold placards and banners.

Suvendrini Perera speaking outside Central Law Courts.

One of the things that has been largely absent from the court proceedings over the past two weeks has been acknowledgement of Fazel as a human being and friend rather than his status as a ‘detainee’ which defined his final days, months and years. Pamela Curr, who was a friend of Fazel’s offered these words about the man she knew,

‘We knew Fazel as a gentle, quiet man who couldn’t understand why he was still in detention because he was found to be a refugee. All he wanted was freedom and peace. He was in the community for eight months, during this time he spent his days helping others, riding his bike and looking after his friend’s dog.’

As long as detention centres exist, people will continue to die within their walls. The scope of this Inquest has not allowed for the consideration of systemic issues. We maintain that deaths in detention, alongside the forms of abuse, violence and punishment that people in detention experience, is a systemic problem. As a systemic problem, it requires a systemic solution. We believe the best way to stop deaths in detention is to end mandatory detention. As boats are being turned back and asylum is being denied, most refugees and people seeking asylum who remain in detention have been in detention for a prolonged period. This is cruel and unsustainable – people cannot be left to deteriorate in detention indefinitely. Alternative solutions need to be enacted as a matter of urgency. We echo the calls for freedom that have been cried through fences for many years. We will continue to stand in solidarity with those targeted by immigration authorities, called by numbers not names and constantly compelled to try and assert their humanity in conditions that deny it.’


As protesters began to gather outside of the court this afternoon with banners and photos of Fazel Chegeni Nejad, a man drove past in his car who recognised the photo of his friend. He parked his car and came to join the group. It was if some force had compelled him to cross paths with us. As I exited the court building I saw him bearing a placard. Following the formalities, he told me that he knew Fazel from the time they’d spent together at Curtin IDC. Fazel had stayed at his home while he went through the stressful court case upstairs that changed the course of his life. He noted that he’d seen media reports that the inquest into Fazel’s death had began last week and it made him happy to see us there. He asked with uncertain eyes if there was anything he could do – this is a question that many of us continue to ask ourselves when confronted with the extreme violence and neglect that people like Fazel continue to be subjected to.

Day 9: August 9, 2018 by Suvendrini Perera

This has been a week of driving rain, icy winds and uncharacteristically grey skies in Perth. At times they cast a strange and lurid light on the Central Law Courts, where the inquest is proceeding. These courts are part of the District Court complex, a distinctive structure that sutures the fragment of a neo-classical portico to a type of brutalist glass tower that overlooks it. Contemplating this hybrid facade, with its deliberate welding together of old and new, its theatrical statement portal and accompanying plaque promising a new era of equality before the law, I am prompted to reflect on the strange edifice of justice in the settler state, and the mechanisms by which Australian law attempts to acknowledge that which it simultaneously continues to displace.

A neo-classical portico is juxtaposed against a modern glass building facade. In the foreground the road and public footpath is visible.

The hybrid edifice of settler justice (Photo Suvendrini Perera)

Last week saw the publication of the inquest findings into the death of Hamid Khazaei, who died in Brisbane after being airlifted too late from Australia’s Manus Island prison. Coroner Terry Ryan noted ‘the requirement for an inquest to be held into all deaths in custody in Queensland was enacted to implement recommendations arising from the 1991 report of the Royal Commission into Aboriginal Deaths in Custody. Recommendation 11 of the report reads:

That all deaths in custody be required by law to be the subject of a coronial inquiry which culminates in a formal inquest conducted by a Coroner into the circumstances of the death. Unless there are compelling reasons to justify a different approach the inquest should be conducted in public hearings. A full record of the evidence should be taken at the inquest and retained.’

It is this recommendation of the RCIADC, requiring the conduct of an inquest into every death that occurs in custody, that enabled the inquest into the causes of Hamid Khazaei’s death — and Coroner Ryan’s subsequent finding that unequivocally affirms the Australian government’s responsibility for those held in offshore detention. Yet the bulk of the RCIADC’s more than three hundred recommendations remain unfulfilled. An installation at the recent Sorry For Your Loss exhibition in Sydney featured shredded pages of the RCIADC report to represent the overall ineffectiveness of these recommendations nearly three decades later, as Aboriginal people continue to die in detention and suffer disproportionately higher rates of incarceration.

As discussed elsewhere on the Deathscapes site, Hamid Khazaei’s death from sepsis parallels Ms Dhu’s death in custody from the same cause, only a month earlier, in Port Hedland jail. In their early 20s, both these young lives were casualties of systemic racialised abuse and lethal neglect in custody. Recognizing the connections between the two deaths, the Indigenous Social Justice Association conferred an Aboriginal Passport on Hamid Khazaei’s family in an act of solidarity, and in appreciation of the Khazaei family’s readiness to donate their son’s organs to Australians despite the fact that it was only at the point of death that Hamid was allowed to enter Australia.

Coroner Terry Ryan’s inquest findings for Hamid Khazaei are unequivocal in recognizing the role that the government played in his death:

The Australian Government retains responsibility for the care of persons who are relocated, for often lengthy periods, to offshore processing countries where standards of health care do not align with those in Australia. It is incumbent on the Australian Government to implement sustainable systems for the delivery of health care that meet the requisite standard.

In light of this finding, I kept returning today to a question posed last week at Mr Chegeni Nejad’s inquest by Counsel Linda Black, appearing for the Commonwealth Ombudsman’s office. On Friday, August 3, Ms Black, a consistently diligent and forceful voice during this inquest, asked the Immigration and Border Protection Department’s Superintendent of National Placement, Sally Pfeiffer, whether she agreed that the Commonwealth bore ‘a non-delegable duty of care’ towards those held in immigration detention. Subjected to a flurry of objections and evasions, the question was left unanswered by Ms Pfeiffer. (This issue of a non-delegable duty of care is discussed in detail in the Ombudsman’s 2013  report, Suicide and Self Harm in the Detention Network, part of the dossier of late documents discussed in our dispatch on day 1 ).

As these hearings approach their close, the question of the state’s duty of care towards those in mandatory detention, whether onshore or offshore, remains central. Shortly after Mr Chegeni Nejad’s death, the respected journalist Michael Gordon wrote: ‘Of more than a dozen deaths of asylum seekers in mainland and offshore detention centres and in the community in recent years, including the brutal killing of Reza Barati, a case can be made that Chegeni’s is the most troubling.’ Gordon argued that this was because, through the long duration of Mr Chegeni Nejad’s incarceration, repeated warnings about his condition went unheeded by the Department of Immigration and Border Protection.

The Department’s own procedures for the treatment of refugees who had suffered torture were seemingly set aside, as were the findings of the Ombudsman’s report cited above which identifies five factors that place detainees at higher risk: prolonged detention; past histories of torture; protracted delays in processing and unfair treatment in the system (such as the excessive sentence imposed on Mr Chegeni Nejad by Magistrate Lane and later overturned by the Supreme Court [see day 7]); location in a remote detention centre; and a ‘contagion effect’ of self-harm within the detention environment. At least the first four of these five factors can be seen to apply to Mr Chegeni Nejad.

Will the failure the government to follow its own clear directions on these matters be acknowledged by the inquest findings? In the strange and hybrid edifice of  the law, with its competing agencies and their contradictory claims and agendas, its visible gaps and patches, its asymmetrical entry points, cracks and fissures, is there still room to envisage a possibility of justice, so long deferred, for Fazel Chegeni Nejad?

Day 8: August 8, 2018 by Michelle Bui

Today, the words ‘I cannot recall’ were repeated countless times in evidence. These words, in my mind, were reminiscent of the response of police and medical witnesses during the inquest into the death in police custody of Ms Dhu, a 22 year old Yamatji woman, whose death too was examined in court room 51 of the Perth Central Law Courts. Custodial and medical staff responsible for her repeatedly failed Ms Dhu, disbelieving and disregarding her pleas for help.

Lengthy delays in the holding of inquest hearings can cause lapses of memory on the part of witnesses. But they are also a source of considerable frustration for families and communities struggling to gain an accurate picture of the events surrounding a person’s death.  Frequent memory lapses on the part of people in positions of power or responsibility can breed a deep distrust in investigation processes and come to be seen as a way to escape accountability.

A paper crane pinned to a jacket.

Paper crane worn in court on Day 8 of Fazel Chegeni Nejad’s Coronial Inquest.

One of the questions that arose today was whether, following Fazel’s death, IHMS management had requested  any feedback from their employees regarding the medical care that Fazel had received.  If no such request was received, this begs the question of what (if any) steps were undertaken to consider and critically reflect on what might have been done differently to prevent Fazel’s death and the spontaneous eruption of anger by fellow inmates that followed it.

The New Zealand detainee said the unrest was “an inevitable situation” that stemmed from “a bunch of people that have had enough”.

“We’ve been taken away from our homes, we’ve been taken away from our families. And obviously watching people hurting themselves, there’s been a few deaths now, I think it’s all built up to this situation.”

Quoted in ‘Christmas Island detainees fear retribution following unrest over death of escapee’

At times it seemed that the riot inside the detention centre that was sparked by news of Fazel’s death was cited as a reason for inaction, not its opposite, in the ensuing period. The period of the riot which erupted on the day that Fazel’s body was found was described as an awful time that thrust the detention centre into turmoil and disrupted standard operating procedures. The question  arises, though, whether and to what extent the riot might be seen to offer an  excuse for inaction in the weeks and months following Fazel’s death. The unrest lasted for about three days. It remans unclear what steps were taken between November 25, 2015, and the inquest hearings more than two years later to review the medical care that Fazel received before he died.

While Fazel’s death itself was perhaps not enough to shock the system, the riot — or ‘major disturbance’ in Departmental speak — did.  This disturbance,  orchestrated by Fazel’s fellow detainees, had significant reverberations. It was noted that processes and practices at the centre changed following the riot, though not necessarily as a direct result of Fazel’s death.

Rather than addressing the underlying causes of the riot  — the grief, anguish and anger at the news of Fazel’s death that shattered windows and tore down the fences and walls of the IDC — the response appears to have been largely punitive.  New restrictions imposed as a result of the riot affected not only those who participated, but those who had made a concerted effort to avoid getting involved. After the event, concerns regarding a heavy-handed response on the part of Serco ERT officers and the AFP were reported by multiple sources. At the time, and in the aftermath, violence was met with further violence.

Peter Dutton, Minister for Immigration and former police officer, vowed to ‘crack down’ on anyone who had broken the law inside the Christmas Island IDC. In reflecting on the Minister’s engagements with the media at the time, it would appear that broken windows and damaged property elicited far greater concern than the death of Fazel Chegeni Nejad under his department’s care.

Postscript Day 8, by Pamela Curr

Pamela Curr, longtime supporter of refugees and a friend of Mr Nejad, attended yesterday’s proceedings and offered Deathscapes the following comment:

Really, a devastating day.
One thing that stood out between the attitudes of staff and fellow detainees was empathy. This seemed totally lacking in staff, except for the doctor who saw him only once and on that occasion as an after hours call-out. The patient had terrible headaches, believed that his brain was seeping through his nose and had other distressing painful delusions –and it seems this was just routinely reported with no plan other than to up his dose of anti-psychotic medication.
I found the apparent indifference and lack of curiosity towards their patient by the medical witnesses, with one exception, shocking. It was not revealed in the inquiry whether this was because they had too many patients or that they saw the men as being so “other” that normal medical care protocols did not apply. One after another, according to their responses, had not read the patient file, did not know of his history of previous suicide attempts, did not have on the record in a prominent place his adverse reaction to a particular drug (basic hospital medical record keeping).
A point was made by the doctor that observations on high-risk patients should be done by clinicians not guards. What stood out in questioning to me was the fact that those 24 hour, half-hourly observation sheets which are filled out by guards are not given to the mental health team so there is a total disconnect between care providers and security … Having a guard sitting at your open door watching you is not a therapeutic intervention.

Day 7: August 7, 2018 by Suvendrini Perera

In December 2014, Perth magistrate Barbara Lane resigned, ahead of a Supreme Court ruling that her actions in a case amounted to ‘a breach of procedural fairness.’ It was the end of a career marked by several questionable rulings.  Previously, Lane had been ‘accused by the legal profession of bullying lawyers and handing down substandard decisions’.

It was before this same Magistrate Lane that Fazel Chegeni Nejad had appeared a year earlier in December 2013. He was charged with his role in an unprovoked fracas that ‘lasted about a minute’ inside Curtin Detention Centre. He made a mistaken guilty plea and Lane sentenced him to six months and a day in prison. On appeal this sentence would be overturned by the Supreme Court as ‘manifestly excessive,’ but by then Minister Scott Morrison had already cancelled Mr Nejad’s visa on character grounds under the draconian 501 regulations.

As Pamela Curr of the Asylum Seeker Resource Centre pointed out this morning, it is a bitter coincidence that the inquest into Mr Chegeni Nejad’s death is now underway in the same Perth Central Law Courts where Lane made a judgment that would determine the course of his life. Curr, a friend of Mr Chegeni Nejad, was present at that 2013 hearing and was shocked by the outcome. From here, after his conviction by Lane, Mr Chegeni Nejad’s eventual transfer to Christmas Island, the most remote ‘on-shore’ detention centre where the bulk of the ‘501s’ are held, was perhaps inevitable. This city at the edge of the Indian Ocean, then, is the scene of two defining tribunals, one of Mr Chegeni Nejad’s  life, the other of his death.

As the closest capital city to Christmas Island in Australia’s Indian Ocean Territory, Perth feels very distant from the place where Fazel Chegeni Nejad spent the last days of his life. At today’s hearing, drone footage followed an AFP officer reenacting the trajectory of Mr Chegeni Nejad’s final walk across the IDC to the point where he disappeared from view by climbing over the electrified perimeter fence that until then was believed by centre officials to be unscalable. Beyond this barrier, the camera  circles over the ground where his body was eventually found a day and a half later.  The footage reveals a  a burst of intense green vegetation, very different from the West Australian landscape in which this inquest is taking place. The ground of Mr Chegeni Nejad’s death is described by AFP officers as ‘jungle’ – a word that itself evokes an environment foreign to that of the mainland. ‘Jungle’ is a racially charged word that takes us outside the terrain of the known, the domestic and the Australian.

A digitally illustrated map of Christmas Island showing locations of deaths on and around the island. The island is labelled as 'Not Australia' in accordance with Christmas Island's excision from the Australian migration zone, despite being considered a part of Western Australia.

Christmas Island, the first Australian territory to be excised from the migration zone in 2001, is and is not Australia. Even in previous decades, its status was ambiguous. Until the 1950s, Christmas Islanders lived on the other side of the Australian border. Then, in view of the impending demise of Empire, the British government  transferred ownership of the territory to Australia ahead of its inevitable withdrawal from Singapore. From the outset, Christmas Island was an anomaly in White Australia. It marks a racial fault line, Australia’s divide from the space of Asia.

It is no coincidence that Christmas Island is also the scene of a number of defining events of our recent history, from Captain Arne Rinnan’s defiant attempt to sail the Tampa into Flying Fish Cove in 2001 to the horrific wreck of the Janga off the cliffs of Rocky Point in December 2010. (I use the name Janga, in preference to the official name SIEV 221, to disrupt what Tony Kevin has named as ‘the first act of regimentation and dehumanisation when an asylum seeker boat arrives in Australian waters’. In this sense the label SIEV is akin to the boat id by which asylum seekers are renamed by immigration authorities).

Tracey Moffatt was one of thousands on the mainland to watch the horrific footage that showed the Janga as it crashed and broke up off  the  Christmas Island coastline in December 2010.  As Australia’s official artist at the 2017 Venice Biennale, Moffatt created a complex four- part meditation, My Horizon,  on Australia’s racial, spatial and temporal borders, on families broken up and displaced as Indigenous people became refugees on their own land, their borders overrun by war and violently remade by settler Australia. Vigil, a short film in this sequence, reworks the footage of the break up of the Janga spliced with images of a series of white movie stars who appear to watch transfixed as the boat crashes before their eyes. Moffatt reflected on the scene:

The boat, carrying mainly Iranian and Iraqi Kurds, disintegrated in rough seas before our eyes. It is a tragedy that has haunted me since… We can never fathom the desperation of the people who got onto that awful boat and crossed the horizon and tried to make it to some sort of freedom in Australia. The smashing of that rotten wooden boat is symbolic of how borders around the world are disintegrating. The old world is out, the new world is coming in and borders cannot stay closed.

Vigil, Moffat notes, can therefore be  read as a ‘a blatant commentary on ‘race’. The Christmas Island boat wreck represents the breaking down of a racial divide, an object lesson in the mutability of belonging and the disintegration of the barriers that divide inside from outside. The as yet unexplained manner of Fazel Chegeni Najad’s death, outside the perimeter of the electrified detention centre fence, at the edges of the jungle in the excised territory of Christmas Island, also speaks of this permeability of borders: of the ineffectuality of the fortifications we erect to separate legal from illegal, refugee from citizen; of our doomed attempts, despite our ever more vigilant and violent efforts at ‘deterrence’, to keep the outside from coming in.

Day 6: August 4, 2018 by Suvendrini Perera

When asylum seeker Fazel Chegeni was waiting in Indonesia for a boat to Australia, in 2011, his friend Mansour [not his real name] got sick. Both were Faili Kurds from Iran, but met for the first time outside Jakarta …They had little money, especially Fazel, who had been robbed by a previous smuggler.

Fazel found food and made soup for his sick friend. “He go to doctor, find medicine. Exactly like brother, exactly like mum, exactly like dad. Then I understand he very, very good heart.”

From Ann Arnold’s report, Fazel Chegeni’s death and the truth of our detention system 2016

A paper crane pinned to a jacket.

Paper crane worn in court on Day 6 of Fazel Chegeni Nejad’s Coronial Inquest.

Today, the court heard from a series of witnesses who had all known Fazel Chegeni Nejad as a fellow detainee. Three of them are currently held in IDCs across Australia. Uniformly, the men spoke of Mr Chegeni Nejad as one who, even in the painful conditions of the detention centres, stood out as in need of care.  At Northam, one described him as ‘like a child’, ill and asking for help.

In day-to-day interactions in the compound at Christmas Island, Mr Chegeni Nejad was again described as thin and physically weakened; unable to eat; dressed in the same clothes day after day.  Frequently, he would hold his head in his hands and run his fingers back and forth across his skull to ease the pain. On the last evening he was seen alive, a witness observed him, shivering and holding his head, outside the IHMS medical centre. He said there was something inside his head. The witness offered what support he could: ‘Be strong. Be patient’.

Over the long duration of his detention, four years across detention centres in all parts of Australia, a number of Mr Chegeni Nejad’s fellow detainees were so concerned about his condition that they took it upon themselves to suggest possible remedies or to approach Serco guards on his behalf. These spontaneous acts of care and compassion by men who were themselves caught up in the mesh of detention stands in stark contrast to the Serco and IHMS officials responsible for detainees’ health and welfare. The latter, we heard from fellow detainees today, responded with indifference or with ineffectual treatments (such as painkillers) to the many appeals for help.  At the level of the departmental officials responsible for shuttling Mr Chegeni Nejad across the detention system,  repeated warnings about his deterioration again fell on deaf ears.

A table covered in a lace table cloth is set up in the Melbourne Immigration Transit Accommodation camp. A photo of Fazel Chegeni Nejad is positioned in the centre of the table. Five candles are placed around it with bouquets of flowers on either side. A Christian cross in marked on the table cloth. The room itself looks like it could be a classroom with part of a whiteboard visible in the background.

Vigil for Fazel at Melbourne Immigration Transit Accommodation (MITA), 2015. Photo supplied.

Comparing the resourceful man who found food for his sick friend as they both boarded the boat for Australia in 2011 with the shivering, vulnerable and childlike figure of 2015, I cannot help but dwell on the degree of physical and emotional damage Mr Chegeni Nejad must have endured during his four years of detention in Australia. Despite his experiences of torture in Iran, it is difficult not to conclude that it was these last four years that finally broke him: ‘I thought it was only in Iran that injustices were done,’ he is reported to have said.

The detainees who testified today were determined and compassionate men who showed the same care for Mr Chegeni Nejad that he had demonstrated for his friend four years ago as they both embarked for Australia with hope in their hearts. The witnesses’ care was evident in their coming forward to give evidence despite potential personal consequences, and in the face of the shoddy obstacles posed by a legal machinery that remains deeply monolingual.* They showed themselves to be men of considerable determination and courage. Yet inscribed in their very bearing, and their different responses before the court – sorrow, vulnerability, bravado, fear, defiance –  the signs of damage that prolonged detention has wrought, and continues to wreak on those caught in its toils, were plain to see.

Oh yes, we do injustices here in Australia, too.

*For example, witnesses who gave their original verbal testimonies in their own languages received written transcripts in English just prior to the inquest — making it impossible for those who did not read English to refresh their memories of what happened in 2015. Their difficulties were compounded by at times inadequate interpreting, by technological failures and by consul who appeared unfamiliar with the basic protocols of interpreting. Some of the misunderstandings that transpired were received with titters by the legal bigwigs, but for others present they represented one more link in the chain of indignities we inflict on detainees.

Day 5: August 3, 2018 by Suvendrini Perera

Today brought to the fore the banal machinery through which the system of immigration detention functions: its everyday business, in all senses of that word. An unwieldy patchwork of bureaucratic processes and commercial considerations, together with their intersecting and divergent logics of ‘risk management’ and cost efficiency, binds together the agencies of the Commonwealth department now known as Australian Border Force and the commercial contractors and sub-contractors who act as its enforcers (SERCO, IHMS, the Australian Red Cross, Life Without Barriers and so on). Caught up in this makeshift and unwieldy patchwork, with its multiple processes of bureaucratic accounting, its complex logistics, its technologies of human and risk management with their in-built budgetary imperatives, are the lives of thousands of refugees and asylum seekers — one of them the life of Fazel Chegeni Nejad, ‘The Deceased’.

A range of witnesses offered insights into the the enumeration, management and movement of bodies across the network of detention centres, the routine business of immigration detention. This business begins with the raw accounting technology of the headcount. At the most basic level, to exceed the maximum number of contractually agreed bodies within an individual detention centre at any one time is  to trigger of an increase in the amount payable to SERCO by the Department of Immigration. This was the state of affairs at the Wickham Point IDC in Darwin at the time of Mr Nejad’s transfer, and is, perhaps, one of the last links in the fatal chain of banal decisions that would lead to his death in the jungle outside Christmas Island IDC: his placement on a list of inmates to be moved out of the Wickham Point IDC in order to ‘stabilize’ the numbers and avoid exceeding the headcount specified in the SERCO contract.

Further considerations of cost savings may cast light on the timing of the removal of Mr Chegeni Nejad. A plane was due to be chartered for transfer of another detainee between Darwin and Christmas Island IDCs during the same period. What logistical considerations and efficiencies factored into the decision to transfer Mr Chegeni Nejad at the same time on the same plane? How did these logistical and cost benefits weigh against a different set of bureaucratic processes calculated to account for the health and welfare of individual detainees? In the case of Mr Chegeni Nejad, with his long history across various detention systems and complex health concerns, which forms of ‘risk management’ were prioritized against others?

A tangle of monitoring mechanisms, assessment tools and accounting processes were in place for considering the mental and physical health of inmates and for communicating this information among the various agencies named above. They included, to name a few: the PSP (Psychological Support Program for those deemed to be high risk detainees), the SME (Support, Management and Engagement team tasked with devising a plan for managing such high risk inmates) and the SRAT (Security Rating Assessment Tool for calculating the risk posed by detainees prior to transfers).

A wall outside the Perth Court with signage that reads 'Central Law Courts'.

Before the Law: Perth Central Law Courts (Photo by Suvendrini Perera).

Reflecting on these labyrinthine reporting, assessment and monitoring mechanisms across multiple agencies, I began to wonder not only how they might be understood by the inmates caught up in their toils, but by the individual women and men responsible for their day-to-day implementation. The testimonies of witnesses working in the various agencies ran the gamut of perspectives, from a seemingly deep confidence in the process, to a lesser sense of certainty about their operation. In one instance, a witness who had expressed her concerns about Mr Nejad’s transfer verbally, but had not used any formal mechanisms to do so, was subjected to a bruising cross-examination by Counsel for the Immigration Department who insisted that she had not in fact had any real concerns at the time. Yet the impression after this cross-examination was not of individual bad faith, but of a convoluted bureaucracy whose logic overwhelmed its individual components and determined the ordinary decisions that its employees made on a daily basis.  Highlighted against the banality of these routinized processes is the enormity of their consequences.

In considering the banal operation of Australian immigration detention, I am reminded of recent events in the U.S. context, where an unlooked for outcome of the executive decision to exercise ‘zero tolerance’ against unauthorized entrants from Mexico was the forcible separation at the border of children from their parents. The spectacle of toddlers held behind chain-link fences in a converted WalMart warehouse becomes intelligible as part of the routine operation of U.S immigration, a process activated by its own internal and disjointed logics. The momentum of this chain of events, as we have seen in successive days, is not one that can be simply undone, either by reversal of the executive order or by the direction of the court. Separated families will live with its effects for decades to come.

In Australia, the transformation from within of the Department of Immigration into the Australian Border Force has set in place a seemingly irreversible momentum towards enshrining ‘deterrence’ as the defining principle of policy towards asylum seekers. It is this principle of ‘deterrence’ that determines the daily business of immigration detention, a business that is both like and unlike any other. For its stakeholders it generates both political and financial capital, a profit-making enterprise, one among others. For Australian tax-payers and citizens, it is a costly business – costly in terms that are calculable in dollars and cents and in the incalculable terms of lives lost and harmed in ways we are yet unable to comprehend or compute.

A paper crane pinned on jacket.

Paper crane worn in court on Day 4 of Fazel Chegeni Nejad’s Coronial Inquest.

Day 5 Postscript, by Michelle Bui

Behrouz Boochani’s book, No Friend But the Mountains, was launched in Fremantle on August 3. Following is an extract from Michelle Bui’s speech at the launch:

‘Behrouz Boochani wrote a poem in response to the deaths of fellow Kurds Fazel Chegeni Nejad and Reza Barati entitled ‘Our Mothers’. In this poem, Behrouz wrote, ‘They lost their lives because of injustice. / They lost their lives in a foreign land. / Who was there when their lives were taken?‘ This is a question that has been raised this week at Fazel Chegeni Nejad’s inquest: who was or wasn’t there, who could have been and why certain actions were not taken? These questions are also posed by the death in custody of Hamid Khazaei, whose inquest findings were released this week.

As AFP and Serco officers described how Fazel’s body was found, their descriptions in some ways recalled descriptions of Reza Barati’s murder. His death involved a violent interaction where he was brutally beaten by Salvation Army and G4S staff, contracted by the Australian government, until finally a rock was used to strike his head in a final blow. Fazel’s skull also made contact with a rock, though a question the inquest has sought to consider was whether that came about through an act of suicide or misadventure. Fazel spent 1477 days in immigration detention. In order to understand how he died in these circumstances, the entirety of this period should be considered. The delivery of evidence and court processes has highlighted the connections and continuities between the offshore and onshore detention regimes.’

Day 4: August 3, 2018

‘As lugubrious and dour an epitaph as Australia’s refugee policy’

In this opening week of the inquest for Fazel Chegeni Nejad, we honour his humanity by publishing this  memento mori from the Life Vests series by Ben Quilty.

A painting by Ben Quilty. Shows an anthropomorphic orange life jacket with a facial profile on one side that appears to be screaming.Reproduced with permission from Ben Quilty and the Tolarno Gallery.

As Michael Desmond writes in his catalogue essay, ‘Each vest records the name of an individual, who grasping at hope of a better life, sought refuge in Australia. For each man or woman, that optimistic belief in a future was thwarted – a false hope that would drag them under as surely as a life vest stuffed with grass.… Each life vest is in effect a tombstone, a way of remembering the dead. Together the paintings constitute a memorial, as lugubrious and dour an epitaph as Australia’s refugee policy…Crying mouths appear on several vests but the viewer will never hear the imploring voices. From another vest, a frightened eye looks out, seeking reassurance perhaps, but will the viewer in front of the painting respond?’

The catalogue essay as well as other paintings in this series can be viewed here.

Day 3: August 1, 2018 by Michelle Bui

The only perceptible trace of Fazel in the court room today was a lone paper crane. Throughout the evidence and examinations he was again largely reduced to the ‘Detainee’ or ‘The Deceased’ with former and current Serco officers sometimes referring to him as ‘Nejad’. Jokes continued to be exchanged between various parties during communication breakdowns or disruptions to video links. I couldn’t help but feel these grins and giggles were grossly misplaced in a court examining the death of a man.

A paper crane pinned to a jacket.

Paper crane worn in court on Day 3 of Fazel Chegeni Nejad’s Coronial Inquest.

Some Serco officers expressed that they thought Fazel had looked stressed and like he was not coping. Any such observations or opinions in respect to Fazel’s mental health have been strenuously questioned by counsel for IHMS, who has insisted that without medical training no one was qualified to make such a judgment.

Inquiries along the lines of whether having information about Fazel’s history of trauma and self-harm would have assisted officers in performing their duties were made. Various parties, including the Coroner, acknowledged that many people in detention have a history of trauma and experience mental health issues. If this is the case, it can be questioned whether a system where the primary points of contact are Serco officers would be adequate to address those peoples’ needs? Likewise it can be asked how the safety and wellbeing of survivors of torture and trauma, who may be vulnerable to self-harm and suicide ideation, can be guaranteed in an environment that makes them feel unsafe and where measures taken tend to be reactive?

Serco’s response to the death of Fazel Chegeni Nejad appears to have been securitisation. Since November 2015, regimes on Christmas Island have become increasingly restrictive and arguably more punitive. Freedom of movement has been further curtailed and additional layers of fencing and security have been added around the perimeter.

A former Serco ERT (Emergency Response Team) officer indicated that Fazel had a propensity to climb fences and buildings – insight he had gained while working at Wickham Point IDC in Darwin. Fazel was someone who other ‘detainees’ would bring to his attention though he only recalled seeing him once after his transfer to Christmas Island, prior to his death.

The paper trail that wrapped around Fazel Chegeni Nejad during the 1477 days he was in the custody of the Commonwealth was extensive. This becomes clearer with every reiteration from the Coroner that the volume of materials presented in evidence was already overwhelming and burdensome. With respect to medical records and Serco documents relating to ‘management plans’, the Coroner repeatedly said she believed that only documents relating to the final 54 days of Fazel’s life were necessary to assist her in her inquiry. Counsel acting for the family, on the other hand, insisted that at least documents relating to the weeks before his transfer should be considered—and this was eventually agreed.

Yet the path to Fazel Chegeni Nejad’s death did not begin 54 days before his body was found under a mound of robber crabs, 50m from a prison fence.  This path was laid when he entered into immigration detention 1477 days earlier.

Day 2: July 31, 2018 by Michelle Bui

Today Serco officers who remain employed in various positions at the North West Point IDC on Christmas Island joined the court via video link. Several of the Serco witnesses heard in the inquest thus far have noted their prior experience the prison system, the military and with G4S. As actors within the border-military-prison complex they help reinforce the continuities between military technologies and systems of punishment, deterrence and securitisation within the immigration detention network.

The central question discussed, a question which inevitably arises after a death in custody and not before, was in relation to the provision of training to Serco officers. Of particular interest were the procedures and protocols that should have been enacted in the event of an alarm going off in the control room.

Plastic wrist bands with the word 'Serco' printed on them, similar to tags provided in hospital.

Serco branded wristbands given to detention centre visitors

On the night of Friday 6 November, an alarm sounded in the control room, indicating that the fence had been breached. The control room operator present at the time indicated he had no idea what the alarm meant and had not received any training in regards to operating the control room and interpreting the alarms. When CCTV footage of the control room was shown on Day 1, an AFP officer was compelled to assure the uncertain court room that the Serco officer on the screen was indeed awake. While the officer suggested that his inexperience made him feel nervous and cautious, he appears largely unmoved by the alarm.

Even after it was determined that Fazel was missing, there was apparently no inquiry into the nature of the alarm nor was consideration given to a possible connection between the sounding of the alarm and Fazel’s sudden disappearance.

Throughout the proceedings, counsel for IHMS, Serco and The Commonwealth have indicated staunch opposition to the introduction of information drawn from a report into suicide and self-harm in the Immigration Detention Network published in 2013 by the Commonwealth Ombudsman. this was an attachment to the ‘inflammatory’ letter that caused so much contention on Day 1. In response to the uproar in court by the counsel representing the state and the counsel for family, the Coroner took a disciplinary approach. She indicated that she understood that from the family’s perspective there are other issues they think should be raised, but that she ‘needed to keep this moving along’. The persistent attempt to limit discussion of ‘systemic issues’ may indeed ensure that things keep moving along as they have been for many years with deaths continuing to churn out of these immigration prisons.

Day 1: July 30, 2018 by Suvendrini Perera

A close up photo of a banner held outside the Perth Coroner's Court. It reads 'Killed by the System. End Mandatory Detention!' on the left side and on the right is a drawing of a paper crane with the words 'We remember Fazel Chegeni'.Demonstrators highlight systemic issues outside coroner’s court.

Today, on the pavement outside Perth Central Law Court, we briefly saw Fazel Chegeni Nejad in a handful of tiny, coloured cranes and a white rose. Arad Nik, refugee poet, had brought the rose and a small hand-lettered sign: They suppress us there, and kill us here. The cranes were made by supporters in Perth who were moved by these small gifts that Fazel Chegeni Nejad had bestowed on others during his life. The itinerary of his confinement included almost every onshore detention centre, before coming to a fatal end on the periphery of the most remote of them all, the North West Point Immigration Detention Centre on Christmas Island.  Having escaped from the centre by scaling its electrified fence, Mr Chegeni Nejad was found dead some 36 hours later in the surrounding jungle. The immediate cause of death appeared to be ligature compression of the neck. He was 34 years old.

For a few minutes the sign lay on the pavement, beside the rose and the carefully folded paper cranes, while demonstrators held up a banner, Killed by the system. Nik personally thanked each supporter for being there. It was the only grace-note in an unrelentingly grim day.

Inside the courtroom there were few traces of Mr Chegeni Nejad:  he was reduced first to a boat ID, and then, simply, The Deceased. For his family, represented by Claire O’Connor SC, the barrage of lawyers representing the Commonwealth, SERCO and IHMS had no expression of sympathy. Both his history of torture in Iran,  plainly marked on his body, and his status as a Faili Kurd who could not be forcibly returned, testified to his status as a genuine refugee; yet the emphasis was on the means of his illegalised arrival in Australia.

From the outset it was apparent that the central question would be to what extent the inquest would consider Mr Chegeni Nejad’s story within the structural and systemic context of Australian detention, and in particular the actions of its enforcers, IHMS and SERCO. Despite persistent efforts by Counsel O’Connor to introduce documents relating to these issues,  Coroner Sarah Linton referred to a prior Directions Hearing in which she had laid out the parameters of the inquiry.  During the former’s questioning of SERCO’s senior manager at the time of Mr Chegeni Nejad’s death, the Coroner repeatedly  made statements such as, ‘we have to back away from more systemic things.’ At another point, she directed, ‘If we could narrow back down.’

During the previous session a lengthy discussion had ensued about the admissibility of a report by a nationally known expert in refugee health that Counsel O’Connor had sought to introduce the night before the hearing commenced. The move was strenuously opposed by Counsel for IHMS and by the Immigration Department on timing and grounds, with IHMS Counsel describing it as an ‘inflammatory’ document, and questioning the appropriateness of the expert to offer an opinion on the case. After lunch, the Coroner ruled that the expert’s report would not be admissible in evidence during the inquest, while leaving open the possibility of a submission after the hearings had concluded (though this was again opposed by Counsel for IHMS).

Today’s hearing raised a multiplicity of questions precisely about the systemic issues relating to every stage of Mr Nejad’s detention: the inadequate provision of care to a refugee who had suffered torture before his arrival in Australia; the cancellation of his visa on character grounds following a harsh decision by a Perth magistrate; the decision to transfer him to Christmas Island detention centre just days before he was due to attend a pre-arranged appointment with a neurologist in Darwin.

These questions, which the inquest will perhaps address in later hearings, are to be discussed in forthcoming dispatches. Today, I am haunted by the fleeting glimpse of a man who spent hours folding cranes for people he would never meet. Deploring the late submission of the folder of documents by the family’s Counsel last night, the IHMS Counsel, Mr Owen-Conway QC, was moved to wax poetic about being disturbed at the ‘witching hour’; he felt, he said, as if he had seen Hamlet’s ghost before him. Yet it was not the ghost of Hamlet’s father, nor even that of Banquo, that troubled the court today, but the unquiet sprit of Fazel Chegeni Nejad. At one point during the hearings I heard his voice: ‘I am scared to kill myself’, he is quoted as saying to a health worker. To some these words seemingly indicated ambiguity as to whether or not he was suicidal. For others of us listening, though, their sense could not be more clear: this was the plea of a tortured and tormented man, crying out for help that did not come.

Twitter Moments on Fazel Chegeni inquest.

A series of daily dispatches from the coronial inquest currently underway in Sydney for Mr David Dungay, Dunghutti Warrior.

Text by Joseph Pugliese
Photos by Joseph Pugliese unless otherwise noted

‘In Sydney, his name is David Dungay. In New York City, his name is Eric Garner.’
Hawk Newsome, Black Lives Matter


‘From day one of the inquest, the extended Dungay family has been in attendance in court with their children. There is one baby and a number of children and teenagers. They sit together or with family members. When the traumatic video of the death of Mr Dungay is shown (it has been shown every day of the inquiry thus far and it never gets easier to watch), different family members and supporters take the children out of the courtroom. They can be seen playing either in the foyer or downstairs on the large covered verandah of the Downing Court Centre. As the witness testimonies unfold, I reflect on the strong kinship bonds that bind the extended Dungay family and the care and love they show each other in this painful setting. I’m also compelled to dwell on the strength and maturity of these children. They are here in this court cutting their teeth on the infrastructural racist violence of the settler state and on its fatal and ongoing effects on Australia’s Indigenous people.’

Inquest into the Death of David Dungay, Dunghutti Warrior
Sydney Downing Centre Court, Courtroom 5.2

Family and supporters gather outside the Coroner's court. They hold large placards that read 'Justice Now' and "I can't breathe" with a photo of David Dungay. Family members wear shirts with the same design on them. On the right side family members hold a large, bright painted banner covered in handprints and a portrait of David Dungay.

Dungay family, supporters and activists outside the Downing Centre Court.

Postscript:  August 14 2018


Hear Joseph Pugliese’s powerful unfolding of  the death of David Dungay in this interview with the Doin’ Time show.

Day 10: 27 July 2018

The inquest continued today with the questioning of one of the Justice Health nurses who was in attendance on the day of Mr Dungay’s death in custody. The Dungay family was still coming to terms with the shock announcement yesterday that the inquest would not be brought to a formal closure as it had exhausted its allotted schedule in terms of the court timetable. When the court broke for lunch, the family and supporters staged an impromptu rally. They streamed out of the court complex shouting ‘Justice today for David Dungay’ in a show of defiance.

David Dungay's Mother stands with her right fist raised in the air. She wears a 'Justice Now' shirt in memory of her son.

Leetona Dungay outside the Downing Court Centre.

Leetona Dungay, David’s mother, held a media conference in which she articulated her thoughts, emotions and wishes in the wake of this suspended coronial inquest into the death of her son, David Joseph Dungay. She read from the following prepared statement:

Photo of first page of a statement written by Leetona Dungay.

Photo of second page of a statement written by Leetona Dungay.

Leetona Dungay then addressed the media:

I’m incredibly upset and stressed, with my family here with me, about the lengthy delay that’s taken to get us here today. I hoped and prayed for closure from this inquest, but now we have to wait another year in our fight for justice – to again hear from all those responsible that they don’t ‘recall’ what happened to my son.

As a mother, I will tell youse all in my words of a slow wait of my son’s written death put into a document that is no good for a parent … and that this never ever happens to any parent again.

In the loss of our son, it [the inquest] did open up wounds again and which is going to open up some more wounds in another year’s time.

And I thought it would have been at the end at this coroner’s court today. Unfortunately, it’s not going to be. It’s going to be another year to wait for answers and who’s going to be accountable for the death of my son.

Two women stand beside one another outside the court. Each have a fist raised in the air. One wears a 'Justice Now' shirt and the other wears a 'Stop Black Deaths in Custody' shirt.

Linda Kennedy and Lizzy Jarret outside the Downing Court Centre.

Lizzy Jarret also spoke to the media. She said:

Please, that’s what I’ll say today. I’ll find humility in my pain, and all I ask is please stop killing us.

When the inquest resumed after the lunch break, the questioning of the Justice Health nurse continued. On the completion of her questioning, procedural matters were addressed. The Coroner then announced that, instead of the inquest resuming in June 2019, he had identified the possible earlier date of 4 March 2019. All parties agreed to resuming the inquest on this new date and the inquest was closed until next year.

After taking my leave of the Dungay family, supporters and friends, I left the court complex feeling the emotional impact of the family’s pain – they had not received vital closure. As Leetona Dungay underscored in her media conference, the inquest has opened up wounds over the loss of her son. And the resumption of the inquest next year would again refresh those wounds. By then, three and a half years will have lapsed since the brutal death of her son in a cell – three and a half years to wait for the possibility of justice.

Spray painted banner that reads 'Justice for David Dungay'

Justice for David Dungay banner draped over the stairs leading to the Downing Court Centre.

As I walked out of the Downing Court Centre building, I stopped to look back as the Dungay family and friends slowly dispersed. For the last two weeks, draped over the stairs leading to the complex has been the banner ‘Justice for David Dungay.’ The banner compelled those entering and exiting the court complex to be confronted by this imperative. Spray-painted on a piece of canvas, it was a piece of activism that spoke to the power of street justice. As a charged artefact of street justice, it stood as a challenge to the formal judicial justice that was supposed to be realised within the court complex.

Downing Court Centre.

Looking up at this imposing emporium of settler law, I reflected that there was an unsettling logic to the fact that the settler state has housed its court complex within what used to be a department store: the old Mark Foy’s emporium, a term born in the crucible of empire. The building’s shopping quarters, café and ballroom have been retrofitted to house the settler state’s law courts and offices. In rooms that had once been sites of shopping and entertainment, criminal trials and coronial inquests now unfold. The harrowing video footage of Mr Dungay’s death had been shown in one such room. The screening of that necropolitical video has now graphically overwritten the histories of pleasure and entertainment that had previously transpired in that same room. It has also reanimated those other buried histories of settler genocide and violence that enabled the very building of the emporium on expropriated Indigenous land.

‘Mourning,’ façade of Downing Court Centre-Mark Foy’s Emporium.

Walking past the building on my way home, I read the commodities – gloves, linen, laces and so on – that the old emporium once sold; they were inscribed along the façade of the building. Traced in black mosaic tiles on gold, one item caught my attention: mourning. This emporium traded in death, loss and mourning.

I remember reading in a historical article that, in 1936, when King George V died, many Sydney department stores, including Mark Foy’s, decorated their shop windows with elaborate black-themed emblems of mourning and that shop assistants wore black ties and black armbands to pay their respects to the deceased king.

No such civic displays for the violent death in custody of a young Aboriginal man. I hang on to that one word traced in black and gold – mourning.

For David Joseph Dungay, Dunghutti Warrior, 2.10.1989 – 29.12.2015

Day 9: Thursday, 26 July 2018

Leetona Dungay stands outside the court. She stands straight in front of the camera with her hands are behind her back. She looks slightly down toward the pavement.

Leetona Dungay outside the Downing Court Centre.

Today began with the questioning by Jason Downing, Counsel Assisting the Coroner, of the Justice Health nurse who injected Mr Dungay with the sedative Midazolam as he was held down by Immediate Action Team (IAT) officers in Cell 77 after he had been forcefully removed from Cell 71. It concluded with uproar in the court when the Coroner, Magistrate Derek Lee, announced that, as the inquest had exhausted its allotted two-week schedule, it would have to resume its questioning of witnesses in June 2019.

This news sent shock waves throughout the Dungay family. The family has endured the harrowing ordeal of seeing CCTV and hand-held footage of the last few minutes of Mr Dungay’s life played over and over for forensic purposes. It has listened to testimony documenting in minute detail the various physiological processes that contributed to his death. All of the testimony and expert witness statements have been invariably underscored by the evidentiary burden of Mr Dungay’s desperate and repeated cries of ‘I can’t breathe.’ They have already waited two and a half years for this inquest, only to be told today that their hope for justice is to be delayed by another year.

The outrage felt by the Dungay family is summed up by Paul Silva, a nephew, who exclaimed to the Coroner on hearing the news: ‘In a year another black person will be dead.’ Never has the legal maxim, justice delayed is justice denied, carried such saliency in the context of a coronial inquest.

As I’ve sat listening, in the course of the inquest, to an ever-growing catalogue of instances of malpractice, breaches of duty of care, negligence, and gratuitous cruelty and violence that, cumulatively, contributed to the death of Mr Dungay, I have seen materialise in my mind’s eye the various recommendations that will no doubt issue at the end of the judicial process. The delay in the conclusion of the inquest, and the consequent handing down of the coronial findings, means these urgently needed recommendations will be put on hold for yet another year. This ensures that the practical measures needed to stop yet another Indigenous death in custody along the lines of Mr Dungay’s will be placed on extended hold.

Justice delayed is justice denied precisely there will be no timely redress delivered to the Dungay family for the death in custody of Mr Dungay. The trauma they have lived with since the loss of Mr Dungay, and which has since been compounded by their exposure in court on a daily basis to his final death throes, is something they will need to carry, without judicial resolution, for another year – only to be further revivified and made raw again with their eventual attendance in court in June 2019. For any family that has lost a loved one, this can only be seen as a cruel cycle of psychological torture.

I wrote yesterday of the words repeatedly called by Mr Downing, Counsel Assisting the Coroner, as he requested his legal assistant to mark the time signature of the place where he had asked the video documenting the last minutes of Mr Dungay’s life to be freeze-framed in the course of his questioning. Repeatedly he called, ‘Time please.’ This phrase, in the context of today’s announcement of the extended delay to the conclusion of the inquest, now takes on a perverse meaning that simply adds insult to injury to the Dungay family: they have effectively been told that, as the court needs more time please, they will have to live with the lack of a timely judicial resolution of their trauma.

Finally, the racialised dimensions of this phrase have today fully come to the fore: Black lives do not matter – time please, as we leave the settler system of racialised punishment that was responsible for the death of David Joseph Dungay in the operational mode of as business-as-usual until at least June 2019.

Day 8: Wednesday, 25 July 2018

Supporter holds large 'Justice Now' placard.

Linda Kennedy calling for justice for David Dungay.

Today began with Counsel Assisting the Coroner, Jason Downing, questioning Dr Spasojevic of Justice Health, Long Bay Hospital, who was involved with the management of Mr Dungay’s diabetes. Dr Spasojevic confirmed that Mr Dungay’s blood-sugar levels on the day of his death were asymptomatic and, when questioned as to whether she thought that his eating of rice crackers might constitute a ‘medical emergency,’ she stated that his eating of the crackers was ‘not a medical emergency.’

Dr Spasojevic’s medical assessment of the situation thus contradicted the corrective officers’ evidence given earlier last week, when they asserted that they had summoned the Immediate Action Team to remove Mr Dungay from Cell 71 and to place him in a video observation cell because his eating of the crackers constituted a ‘medical emergency.’ With regard to Mr Dungay’s eating of the crackers and the possibility that it would raise his blood-sugar levels, Dr Spasojevic replied that she would have merely recommended a subcutaneous injection of extra insulin, which could have been self-administered by Mr Dungay. This medical view was subsequently supported by Dr Cromer, an endocrinologist, who stated when questioned that ‘removing the biscuits would not be a medical emergency’ given his certified blood-sugar levels on the day.

When David Evenden, Counsel for the Dungay Family, questioned Dr Spasojevic, he put on record the family’s concern that Mr Dungay was eating the biscuits because he had often complained to them ‘that he was not getting enough food.’

The Counsel Assisting the Coroner subsequently questioned Professor Brown, Emergency Physician, Royal Brisbane Hospital. Professor Brown gave expert evidence on the issue of Mr Dungay’s death due to positional asphyxia. Professor Brown outlined how the prone position and restraint under which Mr Dungay was placed ‘were likely contributors’ to his death, together with other co-factors, including agitation and his struggle with the correctional officers. By being held in the prone position, Professor Brown concluded that Mr Dungay would have experienced an inability to take deep breaths and an inability to expand his chest, which caused the congestion of blood to his head and which, in turn, resulted in his cardiac arrest.

Significantly, Professor Brown stated that ‘a person suffering from positional asphyxia can still talk and cry out, even as they are running out of oxygen in their blood stream.’ This medical view undermined the prior evidence given by a number of the Immediate Action Team that, in their view, because Mr Dungay could talk – that is, through his repeated and ever more desperate cries of ‘I can’t breathe’ – then he could breathe. One can hear the IAT officers in the forensic video emphatically say to Mr Dungay, ‘If you can talk, you can breathe.’

In the course of Professor Brown’s questioning, the CCTV and hand-held camera footage of Mr Dungay’s forced removal from his cell was again shown to the courtroom. Today, the focus was on the scene of Mr Dungay’s complete collapse after he had been placed in Cell 77. The questioning focused on the level of life support given to Mr Dungay by Justice Health staff and the attending corrective officers. The scene of medical assistance given to Mr Dungay appeared to be a panicked shambles, as it included a gaping eight-minute hiatus between the administering of cardiac massage and CPR to a patient who had just suffered cardiac arrest. Professor Brown pointed to the critical absence of a team leader to direct the life support procedures.

Moreover, the medical team ‘then forgot to remove the cap from resuscitation equipment.’ The footage showed the cap falling out of Mr Dungay’s mouth. It also showed Mr Dungay being incorrectly placed three times in the recovery position when, according to Professor Brown, he should have been kept on his back while constant cardiac massage and CPR were administered. ‘You don’t put someone in the recovery position in the middle of a cardiac arrest, it’s just not helpful, Brown said. ‘You shouldn’t ever have to return to the recovery position if you haven’t recovered.’

Professor Brown remarked, after reviewing the video, that ‘Mr Dungay would have survived with adequate life support.’

The video showing Mr Dungay’s collapse in Cell 77 was impossible to watch as, armed with knowledge after the fact, I was in the position of knowing that I was witnessing the death of this young man.

Again, in order to fulfil the requirements of forensic analysis, Mr Downing inevitably freeze-framed the relevant scenes of the video for the witnesses’ consideration. Prior to Mr Dungay’s collapse, this freeze-framing entailed the momentary transfixing of his life in a sort of premonition of the death that was to come. With the video screen now showing the scene after Mr Dungay’s collapse, the freeze-framing of his life assumed the dimensions of a double death.

At every relevant stopping of the video, Mr Downing would call to his legal assistant ‘Time please,’ so that a time signature was recorded of the scene in question. In the course of this process, this purely procedural call for temporal notation assumed a range of significations that, for me, overwrote the phrase’s forensic burden.

Long after leaving the courtroom, the call, ‘Time please,’ continued to resonate for me – not as a call for temporal notation, but rather in terms of a plea; more precisely, in terms of a burning appeal to be able to stage a temporal reversal, to be given the time to undo a fatal scene of violence:

Time please, to stop the assault inflicted upon Mr Dungay’s body.

Time please, to heed his desperate cries to be able to breathe.

Time please, to offer him the adequate life support that would have ensured that he would continue to live.

Time please, so that he could once more be able to enjoy the loving embrace of his family.

Time please.

Day 7: Tuesday, 24 July 2018

A detail photo of the handpainted banner used in the demonstration outside the court. It reads 'Our Dunghutti Warrior' at the top above the portrait of David Dungay. Below it reads 'Rest in Peace David Joseph Dungay. 2-10-89 29-12-15.'

Artwork by Simone Pash

This last week has seen the correctional and clinical history of Mr Dungay unfold in the course of the inquest into his death. All the material presented in court has been processed through the judicial grid of ‘forensic’ and ‘admissible evidence.’ What would one make of this deceased young man, David Joseph Dungay, if this were all that one could ever know of him? How can this legal and clinical, and thus objectifying, frame ever do justice to the complex life of a young man briefly caught in the forensic prism of a coronial inquest – precisely when, by the very definition of the genre of the coronial inquest, the person is deceased?

Mr Dungay can never appear in flesh and blood in this judicial space where all the witnesses speak of or on behalf of him. He can never intervene to set right all of the possible misrepresentations and skewed accounts of his brutally terminated life that transpire in this court of law.

All of this causes me to reflect and to conclude that, within the necrological space of the coronial inquest, the deceased can never be the sum of the forensic and clinical evidence that will be bound and archived at the close of the proceedings. And that everything about Mr Dungay that both exceeds and escapes this coronial frame can only ever be truly known, in all of its richness and complexity, by his family and his friends.

In a short video statement, Lizzy Jarrett, Gumbaynggirr Dunghutti Bundjalung, speaks of David Joseph Dungay in terms that will never be articulated in the very court of law that is so preoccupied with both his life and death. She speaks of all the vital dimensions that constituted his short life.

Video supplied by Lizzy Jarret, ISJA

Day 6: Monday, 23 July 2018


‘We still don’t know the words and documents that could write the death of my son, and the truth in those documents. I hope the truth of every injury on his body and what caused his death will be revealed in those documents and all of the testimonies.’

Leetona Dungay

Leetona Dungay and Dylan Voller stand together, both with a fist raised in the air.Leetona Dungay and Dylan Voller (Photo by Lizzy Jarrett).

‘Two warriors affected by incarceration in this country with different outcomes,’ says Leetona Dungay, David Dungay Jnr’s mother. For the Dungay family, ‘it is a comfort and a victory that Dylan Voller has survived because he is a very strong warrior.’ She believes her son ‘did not survive because he was in the hands of Corrective Services who failed in their duty of care.’

Today Senior Officer Bagley presented evidence that, according to Mr Dungay’s medical records, he suffered from psychosis (due to schizophrenia), diabetes and asthma. Mr Dungay’s clinical history was, after the fact, laid out in court. I say after the fact because, in the course of today’s proceedings, it was revealed that his medical condition, including psychosis and unstable blood-sugar levels, ‘caused him to have outbursts and agitations.’ Yet it was also put on record today that Mr Dungay was punished for behavioural issues during his time in custody, including being placed in 7-day cells, that is, being confined to his cell for a week. Mr Dungay was, in other words, punished for behavioural issues that were caused by his underlying medical conditions. This constitutes only one instance of the travesty of fair treatment that characterises Mr Dungay’s traumatic and fatal period of imprisonment in the racialised carceral system of the state.

In the course of his many years in a number of NSW goals (including, Junee, Lithgow and Silverwater), Mr Dungay’s mental health began to deteriorate so that by 2013 he was deemed to be a ‘correctional patient’ and transferred to Ward G, Long Bay Hospital.

On the day of his death, when the Immediate Action Team was called in forcefully to remove Mr Dungay from his cell (ostensibly because of concerns about his blood-sugar levels), rather that remove the packet of biscuits he was eating, none of his clinical history was taken to account. In fact, it was revealed today that the Immediate Action Team had a blanket policy of how to deal with inmates across all the different units of the goal: their policy, in terms of their standard operating procedures, was not to differentiate between the mentally well inmates housed in other units of Long Bay Goal and the mentally ill inmate-patients in the psychiatric ward of Long Bay Hospital.

In other words, there appears to be no policy in place in either Long Bay Goal or Long Bay Hospital that requires correctional officers to be briefed about any medical conditions, such as mental illness, that might significantly affect the behaviour of an inmate or patient. There is thus a failure to take into account an inmate’s or patient’s disability when assessing their behaviour or when correctional officers, such as the IAT, move in forcefully to extract them from their cell. Mental disability in, of all places, the psychiatric ward of Long Bay Hospital, fails to figure in such instances. Regardless of the psychotic stress and agitation that Mr Dungay was experiencing, he was treated by the IAT officers as simply another inmate devoid of any medical conditions that were actually impacting both on his mental state and that could, in turn, contribute to his possible collapse, if not death, when placed for an extended period in a prone position. One officer, Officer A, appeared to acknowledge this fact when he ‘said not knowing about the medical factors and complications with an inmate meant he was not properly equipped to do his job, and it was a failing in the system.’

On the day of his death, the Immediate Action Team deployed, in the process of ‘extracting’ Mr Dungay from his cell, sustained force on his shoulders and lower back while he was in a prone position. Even when he was lifted up by the IAT officers and escorted from Cell 71 to Cell 77, Mr Dungay’s head was bowed forward to prevent him from spitting blood, thereby enhancing his risk of succumbing to positional asphyxia.

On the day of his forced removal from his cell, the Immediate Action Team were not briefed, prior to their forced extraction, to take into regard the fact that his psychosis, diabetes, asthma and excess weight all put him at risk of positional asphyxia and that thus his repeated cries of ‘I can’t breathe’ were not ‘diversionary tactics’ but the desperate pleas of a man who was literally suffocating. It was revealed today that five out of the six IAT officers who forcefully removed Mr Dungay from his cell had never attended training in positional asphyxia and that it was not mandatory for IAT officers, including those who actually work in the mental health unit of Ward G, to have any training in mental health.

David Evenden, Counsel for the Dungay family, suggested to Senior Officer Bagley that the Immediate Action Team ‘did not exhaust all their use of options for negotiation or persuasion before using force – other than the [issuing of a] Proclamation, they did not deploy any de-escalation techniques on the day.’ Significantly, a de-escalation option that was available to them was the calling of an Aboriginal Liaison Officer trained in culturally appropriate ways of negotiating with an Indigenous inmate or patient. No such officer was ever called. The IAT officers, in fact, framed their issuing of two Proclamations as, in effect, their use of de-escalation techniques. The first Proclamation issued by the Immediate Action Team consisted of the officers declaring to Mr Dungay that he needed to place his hands through the slat of his cell door in order to be handcuffed. They gave Mr Dungay 30 seconds to a minute to comply. The second Proclamation consisted of exactly the same order – with exactly the same time frame given for Mr Dungay to comply.

As the father of a son who suffers from chronic psychosis, I can only reflect on the cruel absurdity of issuing such a Proclamation to a patient in a mentally agitated state. Operative, however, in Mr Dungay’s fatal situation was yet another more fraught dimension inscribed by the colonial history of the Australian settler state.

I can think of no more inflammatory term than ‘proclamation’ to issue to an Indigenous prisoner of the Crown. ‘Proclamation’ is a term which comes freighted with a history of settler-colonial violence – beginning with Governor Arthur Phillip’s proclamation of the foundation of the British colony at Farm Cove, Port Jackson, on the 26 January 1788, and culminating in Governor Lachlan Macquarie’s public proclamation of war against Aboriginal people on 4 May 1816, which led, amongst other violent outcomes, to the Appin Massacre. Macquarie’s proclamation was underpinned by the following orders:

I have directed as many Natives as possible to be made Prisoners, with the view of keeping them as Hostages until the real guilty ones have surrendered themselves, or have been given up by their Tribes to summary Justice. — In the event of the Natives making the smallest show of resistance – or refusing to surrender when called upon so to do – the officers Commanding the Military Parties have been authorized to fire on them to compel them to surrender; hanging up on Trees the Bodies of such Natives as may be killed on such occasions, in order to strike the greater terror into the Survivors.

Situated in this bloody historical context, the inflammatory and culturally insensitive term ‘proclamation’ should immediately be scrapped from the lexicon of correctional officers in any of their dealings with Indigenous prisoners. This move, however, will have little effect unless the system of racialised punishment that underpins the carceral system of the settler state is abolished.

Day 5: Friday, 20 July 2018

Today in court they once again showed the harrowing video that documents the last minutes of Mr Dungay’s life. It has been exhibited every day this week. The video captures the overwhelming forces visited upon Mr Dungay’s body by the Immediate Action Team (IAT) during the process of his removal from Cell 71 and his relocation to Cell 77, where he died.

The video is an invaluable piece of forensic evidence. It constitutes the corpus delicti or body of evidence of the crime scene. The repeated screenings of the video are an essential part of the process of interrogating each IAT officer in the context of the video evidence that tracks their actions on the day. Yet the video also exceeds the parameters of forensic exhibit. Each screening of the video in the courtroom generates a range of unsettling significations. These different significations insert it within an historical archive that is larger than either the discipline of law or the space of the courtroom.

In the process of exhibiting the video in court, the lawyers repeatedly freeze-frame relevant images that need to be analysed and discussed. This methodical stop-start process effectively works repeatedly to section off Mr Dungay’s body and life. His already brutalised body, evidenced by the blood on the cell floor, is further violated by this practice of symbolic violence. Each stilled frame momentarily suspends Mr Dungay’s repeated cries of ‘I can’t breathe,’ only to revivify his trauma once the video is again set in motion. This stop-start-stop process reproduces a staggered vision of torture that, each time, culminates in that fatal moment of collapse and the complete cessation of Mr Dungay’s breathing. Leetona Dungay, David’s mother, speaks to this unbearable fact: ‘It’s a terrible way to get justice that you’ve got to watch the way that your son’s gonna die at the end.’

Leetona Dungay stands outside the court with her fist raised in the air.

Leetona Dungay outside Downing Court Centre.

In this court of law, the corpus delicti of this video also ensures that Mr Dungay’s filmed body becomes the property of the Crown. Between the two screens upon which the video is projected, on the facing wall of the courtroom directly above the Coroner, is affixed the royal coat of arms of Britain. All the power of the Australian settler state flows from this sovereign icon. All the power of Australian settler law is vested in this symbol: it is what makes it sovereign. Yet it is the very legitimacy of this settler sovereignty that is unsettled and interrogated by the very presence of the Dungay family in this court of settler law. As a people who have never ceded their Indigenous sovereignty, they are calling the settler state and its murderous carceral system to account. Leetona Dungay says: ‘Of these people that were there on the day of my son’s death … I would like them to be accountable … I will do anything for justice.’

A large group of supporters gather in the evening with an Aboriginal flag, placards and banners highlighting deaths in custody.David Dungay rally outside Correctional Services NSW (Photo by Rachel Evans).

Following the end of court proceedings today, members of the Dungay family, their supporters and activists rallied outside the headquarters of Corrective Services NSW, Haymarket, protesting at the ongoing Indigenous deaths in custody. Speakers at the rally included: Lizzy Jarret, Gumbaynggirr Dunghutti Bundjalung; Uncle Ken Canning, Chairperson of the Indigenous Social Justice Association (ISJA); Paddy Gibson, Jumbunna Institute for Indigenous Education and Research and Raul Bassi, member of ISJA.

Three people stand beside one another, holding placards. One of the placards highlights the death in custody of Rebecca Maher, a young Aboriginal woman. The other shows a photos of a man in hospital bed with ankle cuffs on.

Lizzy Jarrett, Raul Bassi and Dylan Voller, David Dungay rally outside Correctional Services NSW (Photo by Rachel Evans).

A large group of supporters gather in the evening with an Aboriginal flag, placards and banners highlighting deaths in custody. Protesters raise their fists in a display of resistance.David Dungay rally outside Correctional Services NSW (Photo by Rachel Evans).

Lizzy Jarrett and Raul Bassi hold a placard highlighting the death in custody of Rebecca Maher. It reads '19.07.2016 Rebecca Maher, 36. Mother of 3 illegal paperless arrest. Dropped in cell 1:00AM, dead at 6:00AM'.

Lizzy Jarrett and Raul Bassi at the David Dungay rally outside Correctional Services NSW (Photo by Rachel Evans).

Day 4: Thursday, 19 July 2018

From day one of the inquest, the extended Dungay family has been in attendance in court with their children. There is one baby and a number of children and teenagers. They sit together or with family members. When the traumatic video of the death of Mr Dungay is shown – it has been shown every day of the inquiry thus far and it never gets easier to watch – different family members and supporters take the children out of the courtroom. They can be seen playing either in the foyer or downstairs on the large covered verandah of the Downing Court Centre. As the witness testimonies unfold, I reflect on the strong kinship bonds that bind the extended Dungay family and the care and love they show each other in this painful setting. I’m also compelled to dwell on the strength and maturity of these children. They are here in this court cutting their teeth on the infrastructural racist violence of the settler state and on its fatal and ongoing effects on Australia’s Indigenous people. They are here learning of the dangers they risk facing as they grow into adults. They are here, in a court of law, absorbing and building up their store of resilience and love in order to survive, defy and flourish despite the transgenerational trauma they experience in their everyday lives. How can one shield an Indigenous child from trauma when it is actually one of the pervasive system-effects of the settler state? Unintentionally, and well beyond its strictly judicial brief, this court of law of the settler state offers them yet another object lesson for their future.

Day 3: Wednesday, 18 July 2018

Dylan Voller has joined the Dungay family at the inquest in order to offer them his support. Dylan Voller is a victim of torture and the system of cruel, degrading and inhumane punishment at the Don Dale Detention Centre, Northern Territory, where he endured, as a child, being stripped naked, tear gassed and thrown into his cell. He is now most remembered for the shocking image of a figure shackled to a restraint chair, his head encased in a spit hood. Voller comments on the inquest:

It’s similar to sitting in the Royal Commission [into the Protection and Detention of Children in the Northern Territory] – you hear lies continuously, the lies don’t stop to cover their arses. I’m here to support my brother David. In our culture, he is my brother even though I haven’t met him. And I have huge respect for the strength of the family and for the strength they are showing.

[Comment by Dylan Voller offered to Deathscapes for publication, 18 July 2018]

A group of six women, including Leetona Dungay, stand in a row outside the court with fists raised.

Lizzy Jarrett, Auntie Deborah Campell, Leetona Dungay, Cynthia Dungay, Lisa Deluca, Simone Pash outside Downing Centre Court.

Day 2: Tuesday, 17 July 2018

In his evidence, one of the officers says that Mr Dungay was ‘trying to trick the officers’ through his repeated cries of ‘I can’t breathe.’ At this, members of the Dungay family rupture the ritualised white decorum of the court with a burst of heartfelt expletives. The expletives work to expose and mark what the family perceive to be the lies of the settler state’s carceral operatives. Each perceived lie is punctuated with the eruption of expletives. Throughout the course of the inquiry, these disruptive expletives become one way to mark the family’s unmediated agency: raw, angry and impassioned, they bespeak long histories of Indigenous refusal and speaking back to a racialised criminal justice system that rarely delivers justice to those who have died in custody or to their families.

A group of supporters stand outside the court with fists raised.

Dylan Voller, Rachel Evans, Lizzy Jarrett, Lisa Deluca, Simone Pash, Linda Kennedy, Maria Clague demonstrating their support for the Dungay family outside Downing Centre Court.

Day 1: Monday, 16 July 2018

It is the morning of the commencement of the coronial inquest into the death of David Dungay Jnr, Dunghutti Warrior. Outside the Sydney Downing Centre Court, the Dungay family, supporters and activists have gathered. They are holding banners that cite Mr Dungay’s last words: ‘I can’t breathe.’ Impassioned speeches are made protesting the death in custody of 26-year-old Mr Dungay. Soon after the inquest begins, Jason Downing, Counsel assisting the coroner, states that Mr Dungay ‘had been diagnosed to be acutely psychotic with auditory hallucinations and his mental health had deteriorated significantly while he was in custody.’ Mr Dungay was also diagnosed with diabetes and asthma. He was held in G Ward, the psychiatric wing of Long Bay Gaol. As the numerous testimonies now reported in the media evidence, the duty of care that should have been extended to someone suffering from multiple serious illnesses was never forthcoming – on the contrary.

On 29 December 2015, an Immediate Action Team (IAT), a specialist riot response unit, was called to transfer Mr Dungay from Cell 71 to Cell 77, which was equipped with video cameras. The catalyst for this transfer was Mr Dungay’s refusal to stop eating a packet of biscuits because of officers’ concerns over his blood sugar levels due to his diabetes. Rather than remove the packet of biscuits, the officers of the IAT proceeded forcefully to extract Mr Dungay. The video footage of the extraction and removal of Mr Dungay to Cell 77 was shown in court today. It is a harrowing video to watch. Five officers can be seen restraining him, first on the bed of his cell and then on the floor. Mr Dungay, under the weight of the officers and their restraining procedures, begins what will be his repeated and ever more urgent scream: ‘I can’t breathe.’

As he is removed from the cell and dragged across the corridor, he can be seen to collapse, even as he’s gasping ‘I can’t breathe.’ By the time he is placed in Cell 77, Mr Dungay begins desperately to cry ‘I can’t breathe.’ Soon after being injected with a sedative while he is held down, Mr Dungay becomes unresponsive. Despite attempts to resuscitate him, he dies from positional asphyxia, literally suffocating to death in the course of his violent removal.

Close up photo of the placards used at the demonstration. They have a black background with white text. The central image is a photo of David Dungay making backward peace signs, in front of a yellow sun, reflected in a red ocean. The text reads 'Justice Now. Our Dunghutti Warrior. David Joseph Dungay. 2.10.89-29.12.15. "I can't breathe"'. Poster, ‘I can’t breathe,’ outside Downing Centre Court.

Before the commencement of court proceedings, Hawk Newsome, a leader of the Black Lives Matter movement, joined the Dungay family at the rally outside the Downing Court Centre in a powerful show of support and solidarity. He underscored the transnational racial violence that continues to kill Black people in both Australia and the USA: ‘It’s the same story, different soil. It’s the same thing from Long Bay to the USA. In Sydney, his name is David Dungay. In New York City, his name is Eric Garner. Eric Garner called for his life 11 times. David Dungay called for his life 12 times. These eerie similarities cannot go ignored.’

Hark Newsome stands outside the court. He wears a blazer adorned with the words 'Black Lives Matter'. Hawk Newsome, a leader of Black Lives Matter, at the David Dungay rally outside the Downing Court Centre.

On 21 April 2018, a memorial event to celebrate Uncle Ray Jackson’s extraordinary social justice work and legacy was held at the Redfern Community Centre. The late Uncle Ray was President of the Indigenous Social Justice Association, Laureate of the Human Rights Prize of the French Republic (2013) and recipient of an Honorary Doctorate of Letters (2016) from Macquarie University. Uncle Ray was first and foremost an indefatigable fighter for social justice across multiple fronts, including for those in prison, for the victims and families of Indigenous deaths in custody, for the victims of police violence, and for refugees and asylum seekers incarcerated in Australia’s domestic and offshore immigration detention centres.

The event opened with a traditional Aboriginal smoking ceremony, and included speeches by his daughters, Carolyne and Francine Jackson, and his granddaughter, Madika. The memorial event brought together a wide cross-section of speakers including Indigenous Elders, Indigenous families of death-in-custody victims, community activists, lawyers, forensic pathologists, prison abolitionists, feminists, academics, students, queer activists, human rights advocates, families, media representatives, trade unionists, and many others from all walks of life. It is a tribute to the all-encompassing reach of Uncle Ray’s social justice vision that such a diversity of speakers came to the event.

The event also included an exhibition of Uncle Ray’s posters and T-shirts which, collectively, evidenced the social and political history of his social justice activism and work. The memorable event concluded with the unveiling of a commemorative poster celebrating ‘a people’s history of Ray Jackson.’

Ray Jackson: an inspirational fighter for justice

Photo of Vikki Road delivering a speech at an outdoor event. Clear sky and trees visible in the background.

Vickie Roach is a Yuin woman, a survivor of the Stolen Generation and a writer. She gave this speech at Ray Jackson’s memorial celebrations at Redfern Community Centre on April 21

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A photo of the campaign image of Ms Dhu being projected onto a building in Perth. Text on the projection reads 'Justice for Ms Dhu'. Text overlayed above the photo reads "The 26th January means nothing to me, they invaded our country and killed our people, they are still doing it today and no body has been made accountable." - Carol Roe, Ms Dhu's Grandmother'.

‘We mark Survival Day 2017 with this series of comments on the painful death suffered by Ms Dhu in state custody. These statements by women from a range of countries coincide with the Women’s Marches in Washington and sister marches across the world. They articulate solidarities against racist and gendered violence by the state. Ms Dhu’s death and the failure of the court to respond with justice is one of the most egregious instances of this violence.’

Carolyn Lewis, Hannah McGlade and Suvendrini Perera

Statements were made by Judy Atkinson, Rosie Batty, Dawn Bessarab, Elizabeth Grant, Debbie Kilroy, Carolyn Lewis, Melissa Lucashenko, Hannah McGlade, Paora Crawford Moyle, Jenny Munro, Kim Pate, Suvendrini Perera, Sherene Razack, Jana L. Walker and Nicole Watson.

Photo taken by Marziya Mohammedali at a protest for Ms Dhu. A woman is seen carrying a placard of Ms Dhu that says 'Unpaid fines should not be a death sentence', in the other hand she carries an Aboriginal flag. She wears a stop deaths in custody shirt organised by Ms Dhu's family.


In death Ms Dhu leaves us with an important legacy. This legacy is our responsibility to accept that through her death, we are forced to confront injustice at many levels. Our actions could be her long-term legacy.

I want to focus on three layers of injustice in particular.

First, we need to fully investigate the ongoing injustice of violence against Aboriginal women, with the lack of real and relevant services to met their specific needs. Even when a woman, for a number of reasons, does not seek help specific to the violence she has, and is experiencing, we need a trauma informed service which asks basic questions: is this women experiencing violence?  Does she have injuries that need attention?  Does she need protection from her assailant?  What are her health and well-being needs?

Second, the police response to her unpaid fines was to lock her up. Women in crisis often incur fines, for reasons related to issues of violence-trauma. Recently in reviewing a situation of a woman incarcerated in the Northern Territory, I became aware that her multiple fines, and then incarceration for driving without a licence, were because she was often driving to get away from situations of violence by her partner.  We need a different approach within the legal system, than fining people who cannot pay, and incarcerating them where they do not pay.   Such people are generally in deep trauma crisis and surviving on a day-to-day basis. Trauma specific programs need to be offered to met those critical needs.

Finally, and more critically, we need to continue to confront the criminal neglect and treatment of Ms Dhu by both the West Australian police and WA health professionals. Their behaviour, as shown on television and footage at her inquest, show gross human rights violations. There is a critical need, across all service delivery, for workplaces to have trauma informed policies and practices.  More particularly the workforce must have a knowledge of Aboriginal lives and historical and contemporary circumstances, with trauma specific skills to respond to these critical circumstances.

It is time the workforce across all sectors, has a trauma integrated approach to all human needs, more particularly in the instance of Ms Dhu, the history and situations that put her where she was, to be treated with the depth of disrespect and criminal behaviour that contributed to her death. Attending to issues of violence against Aboriginal women demands a multi-sectoral approach, with all sectors supporting such women in the complexity of their needs, through a culturally specific trauma lens.

Perhaps, in death, Ms Dhu challenges us to work together to change a system that continues to traumatise Aboriginal people, specifically Ms Dhu, both in her life and the impacts of her death on her family and others. Indeed this could be her long-term legacy.

Emeritus Professor Judy Atkinson a Jiman / Bundjalung woman, now retired, has focused on issues of violence trauma healing within Aboriginal families and communities since 1990, more particularly combining community based work with evidence based approaches that are helping change the epidemic of generational violence – trauma – incarceration, a colonial construct which needs urgent attention.

A photo taken by Charandev Singh of a projection onto the old police lockup in Perth. It is of an icon of a woman overlayed with the Aboriginal flag.


Like the family of young Ms Dhu, I know what it is to lose a child from violence that they should never have encountered.

As a young victim of family or intimate partner violence, and as an Aboriginal woman incarcerated for unpaid fines, Ms Dhu was in an especially vulnerable situation. The callous and racist treatment demonstrated by members of the police and hospital system towards this victim of domestic violence is unforgivable.

Domestic and family violence is perpetrated against women and children of all cultures and races in Australia. The responses by the legal system charged with protecting the victims of this violence has been less than acceptable.

While Australian governments have now made significant commitment to addressing violence through the National Plan of Action, the challenge is how we can translate these policy commitments to real results that ensure that all who experience domestic violence receive appropriate official responses at all levels of government.

During my last year as Australian of the Year campaigning to end violence against women I have learnt that Aboriginal women and girls, especially, experience violence at unacceptably high levels.

I do not support the continued imprisonment of Aboriginal women and girls for unpaid fines. There is too great a risk that Indigenous women, as victims of violence, will continue to die in police cells at the hands of uncaring police officers who don’t acknowledge their victimisation and suffering.

Ms Dhu’s horrific death in a police cell in regional West Australia is a call to our national conscience. On this day known to many Aboriginal people as Survival Day or Invasion Day, I stand with Aboriginal and non-Aboriginal women and say out loud that Aboriginal women’s lives do matter.

I urge the state government to commence urgent talks with the Aboriginal leaders of West Australia, especially women, to put an end to the private and public forms of violence perpetrated against Ms Dhu, and against all Aboriginal women and girls in their state, and throughout this country.

Rosemary Anne “Rosie” Batty is an Australian domestic violence campaigner and the 2015 Australian of the Year.

A photo taken by Charandev Singh of a projection onto the old police lockup in Perth. It shows the campaign image of Ms Dhu overlayed with an Aboriginal flag with the text '#Justice4MsDhu' below. In the foreground a sign that reads 'Police' with an arrow points toward the building.


Time to change the narrative

The police narratives emerging from the inquest highlight the entrenched nature of racism inherent in their beliefs which had a huge influence on the decisions, treatment and management of Ms Dhu resulting in her untimely death. Evidence by both prison and hospital staff clearly indicate the innate stereotypical narratives and racist beliefs communicated by the police and accepted by the medical staff influenced the inhuman treatment and contempt meted out by them to Ms Dhu. Rather than being judged and labelled as someone who was : ‘exaggerating her pain’ ‘withdrawing from drugs’ ‘behavioural issues’ and ‘faking her symptoms’, Ms Dhu deserved to be treated with dignity and empathy and as a suffering human being in pain. The lack of a stretcher in the lockup raises the issue of duty of care by the police to ensure that Ms Dhu was accorded dignity and treated humanely which she was not. Instead of being silenced, her condition should have been taken seriously and proper medical treatment provided regardless of the beliefs and diagnosis made by the police who are not medical ‘experts’ yet influenced the decisions, diagnosis and treatment made by the medical staff which ultimately resulted in her death.

The coroner to conclude with no blame is to continue the racial narratives in this country which justify the legitimacy of deaths in custody and fail to hold accountable the actions or lack of by police and health professionals whose beliefs and decisions ultimately contributed to the death of Ms Dhu.

Dr Dawn Bessarab is a senior social worker and researcher who has 30 years’ experience and expertise in Aboriginal health and has worked in the areas of justice, alcohol and drug abuse, violence and community development. She is a strong advocate of social justice and human rights.

A photo taken by Charandev Singh shows a man holding an Aboriginal flag in the foreground. In the background a group of protestors at a rally hold a banner highlighting the number of deaths in custody since 1989. It also reads '25 years since Royal Commission into Aboriginal deaths in custody / A national disgrace'.


Ten years ago I sat in the front room of the late Elliott Johnston’s QC’s home reflecting on the Royal Commission into Aboriginal Deaths in Custody (RCIADIC). At the time, it had been over a decade and a half since the final report had been released and on this occasion, I was lamenting the lack of implementation of recommendations. At one point, Elliott, who had been the Royal Commissioner, looked at me over his coffee cup, paused and said “We could have done more.”

Australian society certainly could have done more for young Mrs Dhu, who suffered a prolonged, agonising and humiliating death while in police custody. Too many of the Royal Commission’s recommendations have not been implemented.

If they had, then for Mrs Dhu… Imprisonment would have been only been used as a last resort (rec. 92). Mrs Dhu would not have been imprisoned for a paltry fine default (rec. 120 and 121). On entering custody, her health would have adequately assessed (rec. 126). Mrs Dhu would not have been put in a cell alone (rec. 144). Her family, friends or other support would have been contacted and could have advocated for Mrs Dhu (rec. 145). An ambulance would have been called (rec. 136). The Police’s duty of care would have been exercised (rec. 122).

And if RCIADIC recommendation 134 where police are obligated to treat people in custody humanely had been observed, then in her dying moments Mrs Dhu would not have been manhandled, dragged through the police station like a carcass at an abattoir and shoved onto the bare metal of the floor of a paddy wagon.

The Western Australian Coroner’s Report has been tabled and it makes some recommendations principally calling for systemic change. These are only recommendations as we have failed to make coronial recommendations mandatory (rec 13). We failed Mrs Dhu, as we have failed so many others. Yes, Elliott, we could have done more. 26 years on, we must do more.

Dr Elizabeth Grant is a criminologist, architectural anthropologist, and academic with a distinguished record in the field of Indigenous architecture with specialist interests in the design of institutional environments and reform for Indigenous peoples. She holds the position of the Chief Executive Officer of the Aboriginal Prisoners and Offender Support Services, and consults to communities, industry and government on Indigenous architectural projects. Dr Grant holds an adjunct Associate Professorship at the University of Queensland and an adjunct Professorship at the University of Canberra.

A photo taken by Charandev Singh of protesters marching through the streets. One person carries a placard that reads 'A sick prison system still claiming lives'.


Nothing Changes if Nothing Changes

My heart stopped when I saw the footage of Ms Dhu being dragged by the legs and her head allowed to smash on the concrete cell floor. How could two human beings treat another human in such an inhumane way?  The short answer is that the two police officers cannot possibly have seen Ms Dhu as ‘fully human’.

White privilege is insidious. Too often, our socialisation means that we are unconscious of the racist assumptions behind our behaviour.  The implicit racism of the police was clearly seeping out in their attitude toward Ms Dhu – from her initial arrest (despite being a victim of domestic violence); to the decision to imprison her for outstanding fines for minor offences; to the heartless denial of her extreme pain for 3 days; to this, final, brutal act.  Implicit racism was also evident in the WA Coroner’s decision not to hold authorities and individuals to account for their horrendous treatment of Ms Dhu.

The death of Ms Dhu in police custody was not an isolated incident. It is critical that we see it as part of a continuing pattern of genocide which began with the invasion of Australia.  Aboriginal women and men continue to be traumatised and murdered by the hand of the state.  Our systems and structures continue to force Australia’s First Peoples into a position of subordination and vulnerability.

For as long as we have prisons; for as long as Aboriginal women and men continue to be grossly over-represented in prison populations; for as long as their rates of criminalisation (particularly for Aboriginal women and girls) continue to grow; for as long as our First Peoples are over-policed and over-penalised for poverty and trauma-related ‘offences’ … the Coroner’s recommendations will simply join the litany of broken promises to close the gap in Indigenous disadvantage

Structural racism is protected by a ‘white wall’ of privilege. Until we recognise structural racism as the fundamental issue underpinning black deaths in custody, we’ll continue to see death, after death, after death …

The only way to prevent the death of another Aboriginal woman in custody is to own and begin to redress the systemic racism and sexism which was fundamental to Ms Dhu’s death.

Debbie Kilroy is a former Prisoner, Psychotherapist, practicing lawyer, Australian Human Rights Medal recipient, and CEO of Sisters Inside, a community organisation that advocates for the human rights of women in the Criminal Justice System. Debbie is a strong activist, locally, nationally and internationally, on issues relating to prison abolition. She is the first former prisoner in Australia to be admitted to practise law.

A photo taken by Charandev Singh of Ms Dhu's Grandmother, Mother and Sister stand outside the Perth Coroner's court wearing shirts remembering Ms Dhu and carrying placards. They all loo away from the camera as if consumed in thought.


‘Women walking with Julieka’

Women walking with Julieka, I refer to Carol Roe my cousin-sister, in our way cousin-sister is someone you clearly have a relationship with, someone you hold a special bond with, someone who is significant, someone that connects the heart and souls of many woman. Sister-Carol, Della K and numerous others are the ‘Women walking with Julieka’

This statement is an acknowledgement to all the women in the life of Miss Julieka Ivanna Dhu’s – ‘Dhufish’, Rest in Peace Nana, Julieka is known to me as my nana, I’m one of her many Nana’s that unite and walk alongside her principal Nana in Sister-Carol.

I sincerely acknowledge my niece Della-K Roe, Julieka’s mother who stands beside her mother, Julieka’s sisters, grandmother, aunties and cousins on both sides of her families who’ve walked alongside her life and now take another journey a fight for justice to keep her name ‘alive’.

I need to acknowledge the other women who came into contact with Julieka, those women who were in supposed to look after her, ‘it is simple you failed her’, the findings clearly state that the unprofessional, degrading and inhumane treatment dealt out to Julieka has been extremely distressing and difficult for the women in her family and community. You women will have to live with your actions and appalling disregard for one’s life, a life in your hands you took away from the family that loved her the most. You all heard her voice, saw her pain’, you chose not to walk alongside Julieka your choice was sadly to walk Julieka Dhu to her death.

Women walking with Julieka have come together to fight for her, they’ve stood as one in solidarity, strength amongst each other, care and love to ignite the power of women to walk together for all women and to continue the Fight for Justice for Julieka. These choices are of strong women who will walk today and always, these are the Women walking with Julieka not the others.

Note: I am family I will refer to Ms Dhu as Julieka.

Carolyn Lewis – Nanda/Widi women, Carolyn is a relative of Miss Dhu and strongly believes enough is enough and their needs to be change to ensure that our grandchildren will not endure extreme racist actions toward their children’s, children.

Carolyn is a strong advocate for First Nation’s women’s grassroots viewpoint in order to generate transformation of mind sets in an ever-changing community services environment.

A photo taken by Marziya Mohammedali, shows a placard carried at a march that reads '22 years old. Justice for Ms Dhu. Stop Deaths in Custody'. It should a photo of Ms Dhu holding up the peace sign.


Nothing is Written in Stone

I never knew Miss Dhu, and now I never will.. You might say, peering in from outside Aboriginal Australia, that her death was hideous, and hideously predictable, and you’d be right. But wait a second. Nobody’s life or death is ever written in stone. Miss Dhu could be alive today, and thriving. Things could be very different.

Like Ms Dhu in life, “Sally” (*not her real name) is visibly Aboriginal, twenty two years old, and given to wearing hoop earrings. Sally has lived on the street, and has seen most forms of conventional violence in her young life. Sally has been beaten by men, and has herself beaten women. Sally’s severely disabled mother is unable to help her much. Yet Sally does not look like going to jail, much less dying there. Why? Because Sally was able, unlike Miss Dhu, to find help through community programs in inner Brisbane, an arguably less racist environment than country WA. At 22, Sally is now a young mother raising her child in stable housing and doing a good job of it. She is clean of drugs, free of domestic violence, and no longer entangled with police.

Like Sally, Miss Dhu could have been helped to leave an abusive partner, the partner who broke her rib and indirectly killed her. Like Sally, Miss Dhu could have been provided with trained people who understood the reasons for her drug use. Like Sally, Miss Dhu could have been supported to make better choices, to battle the white supremacy which killed her in the form of racist indifference to her suffering. But the services which could have helped simply were not there. Funding to black community services – already pitiful – was slashed to historic lows in the 2014 Federal budget. Because Aboriginal lives don’t matter – so why not cut such services to the bone, or outsource them to large corporations who have little clue who they’re dealing with?

The ABS estimates the economic wealth of Greater Geraldton at $5.072 billion. Just over five billion dollars, every one of them earned on or extracted from Yamatji lands. In a less racist State, Ms Dhu could have expected to enjoy some of the fruits of that five billion dollars. But she was Aboriginal in country WA and to be Aboriginal in country WA in the 21st century is to expect little from the State which dispossessed you, and to receive even less.

It could have been so different. We must fight until it is.

Melissa Lucashenko is a prize-winning Goorie novelist from Brisbane. Her essay “Down and Out in Brisbane and Logan” won the 2013 Walkley Award for Long-form journalism. She is widely published.

A photo taken by Charandev Singh of a close up of the John Pat Memorial at the old Fremantle Prison. A didgeridoo lies across it and the Aboriginal flag is reflected in the marble memorial.


In the early 1980’s, Aboriginal communities of West Australia were rocked by the death of 16 year old John Pat in Roebourne following a violent assault by five off duty white police officers. Whilst initially charged with ‘unlawful killing’ an all white jury subsequently acquitted the officers who were reinstated to duty with no further recrimination. Unsurprisingly, the flow of deaths of Aboriginal people in police lockups and prisons continued in WA and across the country leading to nationwide protests and the establishment of a Royal Commission.

More than 25 years after the conclusion of the Royal Commission into Aboriginal Deaths in Custody and its numerous recommendations, little has changed for Aboriginal people at the hands of the justice system. While the Royal Commission did not address issues facing Aboriginal women, the gendered dimensions of state violence are evidenced by Ms Dhu’s death, captured on CCTV. The Coroner’s findings, that effectively excuses all those who played such a significant part in Ms Dhu’s death, highlight the ongoing nature of colonization.

The police could not see Ms Dhu as a victim who was deserving of protection and assistance – her Aboriginality denied her this status. The abysmal failure of the medical professionals involved to provide medical assistance to Ms Dhu showed the continued practice of ‘race-based medicine’ and its fatal consequences. That no persons involved in Ms Dhu’s death were referred to any regulatory body for their actions, found ‘inhumane’, ‘unprofessional’ by the Coroner, proves that justice remains elusive and outside the reach of Aboriginal women.

Aboriginal women of West Australia now comprise more than half the population of Bandyup, the state’s sole high security prison and Aboriginal children more than half of all children forcibly removed from their mothers to the ‘care’ of the state. These figures rise steadily while Aboriginal mothers in West Australia are subjected to family violence at staggering levels and are estimated to be 17.5 times more likely to be a victim of homicide.

Ms Dhu’s death, and all the shocking aftermath, has broken our hearts. In a beautiful song made in memory of Ms Dhu, Aboriginal girls of the Pilbara sing ‘Did Ms Dhu die for nothing? No she didn’t!’

Today we stand together in solidarity with Ms Dhu’s family, in memory always.

Dr Hannah McGlade is the Senior Indigenous Research Fellow at Curtin University. A human rights lawyer and academic, McGlade is the author of ‘Our Greatest Challenge, Aboriginal children and human rights’ which received the Stanner award for excellence in Aboriginal research. Dr. McGlade is the chairperson of Aboriginal Family Law Service which supports Aboriginal victims of family violence in WA. 

A photo taken by Marziya Mohammedali at a Black Lives Matter rally in Perth. A young woman holds up a sign that reads 'A system cannot fail those it was never built to protect' with a red handprint on one side. Another woman carries a placard that reads 'Who do we call when police murder?!'


The single biggest tragedy of colonisation has been to separate us from our sacredness.  This, in the eyes of the state, in the eyes of the community, in the eyes of the system and its designers, and more grossly, when oppression has left little room for anything else, in our own eyes.  Where Freire theorized it, colonial settler states and their inequitable systems that relegated Indigenous peoples and our life ways to the sewers and squalors, perfected it.  The crying shame of our sister Dhu’s death is not that it is symptomatic of a system not working but indeed the opposite – it is symbolic of colonisation working EXACTLY as it was designed.

Australia was built on the acceptance that there were no human inhabitants that existed on those lands.  This desensitised mentality is continually enforced/ratified through the Australian government’s perpetual dehumanizing of its Indigenous people.  Our whānau were deeply impacted by what happened to our sister Dhu and had this to say, “They ignored her pleas and denied her the same respect and rights a non-indigenous person would have received. A pure neglect of duty.” From one of our elders, “Those from the darkness will be returned to the darkness never to see the light again.”  As a whānau, we recommend, a decolonization wānanga for all Australian government employees.  Further, a ten point checklist, 1. Treat every person as if they were your mother, son, brother, daughter, sister, uncle, regardless of race. Repeat nine times.

Paora Crawford Moyle is of Ngāti Porou and Welsh whakapapa, a social worker of 25 years, and is a grassroots activist against the incarceration of Indigenous children into the care of the NZ state. Paora is also a PhD student and lecturer in the school of social work at Massey University.

A photo taken by Charandev Singh at a protest in Melbourne. A man wearing a 'Warriors of the Aboriginal resistance' shirt speaks into a microphone. A man standing to his left carries a 'Stop Racism Now' sign. Another woman wears a shirt with the Aboriginal flag on it.


The most telling comments from the Inquest into the death of Miss Dhu by Coroner Ros Fogliani come at the very end of the Inquest findings on pages 160 and 161 in para 856,857,858, 859 and 860. She is explaining the reasons why Professor Thompson identifies Miss Dhu’s risk factors as follows:-

“In summary and with the benefit of hindsight, it is clear that there are many ways in which Miss Dhu was at risk; her Aboriginality and lack of resources, her age and inexperience at negotiating for help, her injecting drug use that is a risk factor for septicaemia, her living conditions, which increase her risk for staph infections, her Aboriginality and injecting drug use that mean she may be treated less well within mainstream institutional settings”.

Professor Thompson goes on in para 857 to describe this as “institutionalised racism” (p160 and 161)

“Institutionalised racism refers to societal patterns that have the net effect of imposing oppressive or otherwise negative conditions against identifiable groups on the basis of race or ethnicity. Institutionalised racism is manifested in our political and social institutions, and can result in the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin”.

Professor Thompson rightly identifies the culprit as the institutionalised racism of the Police and Medical staff as the greatest of Miss Dhu’s barriers to climb.

The Coroner goes on to point out in para 858 the Miss Dhu’s family submit that this is what happened when miss Dhu presented to the medical staff for treatment on the first instance at 8pm on the 2.8.14

She then recites in the very next paragraph (859) that:-

“I did not find that any of the HHC staff or police were motivated by conscious deliberations of racism in connection with their treatment of Miss Dhu, nor does Miss Dhu’s family make that submission. It is important to be clear on this point”

My question to both (so-called experts) Why is it raised if it is a non-issue? Why then define and dismiss it, when the dismissal fits almost word for word with the description of the institutionalised racism, everybody is at great pains to ignore. On every occasion Miss Dhu presented to the Medical Centre for treatment, Police all considered her to be “faking it”. As her Grandmother asked:-“What, faking her own death”. Medical staff consistently called it:-“ Behavioural issues and drug withdrawal”. Septicaemia develops slowly, in Miss Dhu’s case it took three days to take hold and kill her, sadly no one in charge of her care, cared enough to save her.

I believe it is raised because at the very first opportunity Miss Dhu was subjected to this institutionalised racism that eventually overwhelmed and then killed her. The sub-conscious intuitively racist decision making of all charged with ensuring her safety, failed miserably.

Who raised it first, why. If it was as notes to Miss Dhu’s incarceration, where was the confidentiality in the Police station, where innuendo very quickly became uncontested fact. Burgess, Bond, Matier all Police generally disregarded Miss Dhu’s right to adequate care and confidentiality while in their custody. The only time patient confidentiality became an issue for the Police was very close to her death. The Medical staff, Hetherington (did not take temperature or Xray), Lang (did not believe Miss Dhu about the broken ribs), and others,  pft wouldn’t let em treat my dog let alone another human being. With the exception of Nurse Jones, none showed themselves in a good light and all succumbed to the institutionalised racism to the point where standard health checks like temperature and X rays were not done for Miss Dhu. Another case of murder by institutionalised racism is buried with Miss Dhu’s remains.

It is important to note on p48 the description of Premature Diagnostic Closure in considering whether Miss Dhu’s death was preventable, where Dr. Dunjey elaborated on the premature and deadly diagnosis of Miss Dhu.

It is also important to note that the Coroner was not instructed to look for instances of neglect or findings of criminality against anyone. She leaves that for the racist state of Western Australia.

It is also important to note that before Miss Dhu was declared dead at 1:39 on the 4.8.14, internal affairs police were already on a plane to Port Hedland.

It is also important to note that Miss Dhu’s death was preventable and she could have been saved if she had been properly diagnosed and treated on the first or second occasion presenting at the Medical centre. She was never formally diagnosed with anything until her Inquest when the Autopsy results were given. Antibiotics could have saved her on either of these visits. It was simply too little too late on the occasion of her third and final fatal visit to the Hospital.

It is important to note that the WA Police made changes to its Lock Up Procedures Manual 18 days after the death of Miss Dhu, but made no admission of culpability to the Coroner. I think the Lock up update is their admission of guilt, conveniently covered up by the Coroner.

All are culpable, but will any be charged. I think not, and that is the GREAT crime in this beautiful land and it is still called Institutionalised racism.

Jenny Munro is a Kalare Wiradjuri Elder, community organiser and activist. She co-founded the Redfern Aboriginal Tent Embassy and has been a long term Aboriginal Housing rights campaigner. In 2015 she was awarded the Eddie Mabo Award for Social Justice. She is currently the CEO of Mudgin-Gal, a unique service run by Aboriginal women, for Aboriginal women. Mudgin-Gal means ‘women’s place’.

A photo taken by Charandev Singh shows a man holding a printed placard that reads 'Stop violence against women:...'

State violence against Indigenous women is no less shocking, just because it is not new. It shook me to my core to see the videotape of Ms Dhu’s horrendously brutal treatment and death.

Ms Dhu’s death in police custody is illustrative of the worst and most tragic of many racist consequences of colonization in both of our countries. Ms Dhu should never have died in police custody, but you would be forgiven for observing that her life history predetermined her death. Police arrested Ms Dhu when they were called because she was in need of protection from her violent partner. Police, doctors and nurses ignored Ms Dhu’s pleas for help and Ms Dhu died 20 years after the findings of the Royal Commission into Aboriginal Deaths in Custody in Australia.

We must dismantle the racist foundations of our legal and administrative systems and hold accountable those individuals and institutions who continue to kill Indigenous women. Addressing the marginalization and victimization of Indigenous women and girls will also help prevent their criminalization and incarceration.

The time to act is long overdue. For Ms Dhu and too many others, we are too late. We must act immediately to prevent the deaths of others. The time to act is NOW!!

The Honourable Kim Pate, C.M., B.A., B.Ed. P.D.P.P., M.Sc.Dip., J.D., D.U., LL.D. (h.c.) Professor, Faculty of Law (Common Law), University of Ottawa & Special Advisor, Canadian Association of Elizabeth Fry Societies (CAEFS)

Kim Pate is a Canadian Senator and women’s advocate. She has spent the last 35 years working in and around Canadian legal and penal systems, advocating with and on behalf of prisoners. Before her appointment to the Senate she was the Executive Director of the Canadian Association of Elizabeth Fry Societies (CAEFS); a federation who provide services and work in coalition with marginalised women.

A photo taken by Charandev Singh shows a son and mother performing a song outside the Perth Coroner's court. The son plays the guitar while the mother sings 'Forever Young'. In the background a placard can be seen that reads '2 years on: still no justice, still no answers. We remember Ms Dhu'.


On a bleak morning in Perth, as rain poured overhead, a friend sang one of Ms Dhu’s favourite songs, at once a blessing and a lament: May you stay forever young. Images of the vivacious 22-year-old flapped in the wind as court functionaries walked past without a sideways glance. But neither their indifference nor the chill rain could dampen the crowd’s outrage and their determined calls for release of CCTV footage that showed Ms Dhu’s last hours.

These efforts, led by Ms Dhu’s family, eventually succeeded. The footage, made public on the same day as the coronial findings, reveals the relentlessly brutal treatment of Ms Dhu at the hands of the state. It exposes the physical violence perpetrated through actions such as dragging, flinging, shoving and other forms of manhandling of her ill and wounded body, and at the same time lays bare an equally lacerating exercise of psychic violence in the persistent assumptions that Ms Dhu was ‘faking’ her symptoms and was malingering, addicted, manipulative and hysterical. These entrenched racist stereotypes underpin and licence the physical ill treatment of Ms Dhu; indeed, it is only this framework of racist preconceptions that makes intelligible the inability of medical and custodial staff to recognize that she was seriously ill and to treat her with due care and respect.

Despite the compelling testimony of the visual evidence, the coronial findings followed a pattern that is all too familiar: one in which Indigenous deaths in custody are the outcome of unfortunate chains of random circumstances. Indigenous bodies, it appears, are somehow prone to dying in custody in circumstances for which no one bears ultimate responsibility. While individual officers may receive mild censure, their actions never appear as other than minor factors in a narrative of inevitable demise.

The release of the footage has helped expose the gaping chasm between the law’s inability to see and what is all too painfully evident on the screen. What is made plain here is the failure of the law in W.A, once again, to deliver justice. Once again, when it comes to deaths in custody, W.A reveals itself to be a state of shame.

Suvendrini Perera is a John Curtin Distinguished Professor in the School of Media, Culture & Creative Arts at Curtin University and the lead investigator on the ARC funded project, “Deathscapes: Racialised Violence in Settler Societies”.

A photo taken by Jacob Higgins show people participating in a die-in outside the coroner's court. In the centre of the crowd are two children sitting in a pram.



Pugliese writes of human beings treated as animal carcasses. This is so clearly what Ms Dhu was to her jailors: meat gone bad. Inquests into deaths of this kind, either Canadian or Australian, refuse to interrogate these moments of utter dehumanization. Racism, they typically conclude, has nothing to do with it. Yet racism is first and foremost a pervasive, institutionalized eviction of Indigenous people from the category of the human. When people are regarded as less than human, they are expendable. Marked for death, an invisible checkmark on the skin earmarks disposability. Such deaths never count as murder. We simply accept untimely Indigenous death as natural, a predictable end for a damaged people whose bodies are in a permanent state of decay.  ‘People die,’ one prison guard told a Coroner, implying that there was not much he could do when a prisoner died in the cells. It’s better that they die in the cells rather than on the streets, a police officer opined, unconcerned about the sick prisoner he didn’t bother checking on and who had died on his watch. The failure of professionals to help a sick person, the frequency with which guns or Tasers are used, the numbers of suicides that take place in prisons, (indicating how many prisoners are driven to suicide, and how easy it is for prisoners to kill themselves) and the willingness to risk Indigenous life so easily reveal an abiding disregard for Indigenous life. The same dehumanization is evident in the consistent reluctance in inquests and inquiries among other legal processes, to interrogate those moments when a person’s life is deemed to be worthless. Inquests often paper over the brutality, endlessly recommending that state actors develop a little more cultural sensitivity and remember to check cameras in police stations and hanging points in cells. Oft-repeated, the recommendations, which I call the game of improvement, indirectly confirm that settler society finds it difficult to provide the barest minimum of care and respect to populations that it over-polices and incarcerates at rates that are among the highest in the Western world.  With respect to Indigenous peoples, there is a “failure to respond,” concludes the Correctional Investigator for Canada, Howard Sapers. When we want to understand where racism is in deaths in custody such as Ms Dhu’s, we should begin with this “failure to respond,” asking where it comes from, what it sustains, and how it might change. Could there be a settler colonial state without it?

Sherene H. Razack, Distinguished Professor and Penny Kanner Endowed Chair Gender Studies, UCLA.

A photo taken by Charandev Singh at a Black lives matter protest in Melbourne. A close up of a placard reads 'We are buried up to our necks in a history of violence + brutality against people of colour'.

Statement of Concern Regarding the Death of Ms. Dhu

January 24, 2017

By Jana L. Walker, Senior Attorney, Indian Law Resource Center*

Ms. Dhu’s tragic death in government custody shines a spotlight on yet another discriminatory and seriously flawed national law and accountability system with respect to indigenous peoples. This case makes clear that too often the Australian legal system, like many legal systems around the world, not only does not protect indigenous women, but actually threatens their safety, lives, and human rights.

Indigenous women’s human rights include the right to be safe and live free from violence and discrimination. Though violence against women and girls is recognized as one of the most pervasive human rights violations worldwide, international experts have found the situation of indigenous women to be especially dire. Indigenous women often experience multiple forms of discrimination that make them more vulnerable to other forms of violence. As a result, as indigenous women, we suffer violence, we are murdered, and we disappear at higher rates than any other group of women. Yet, indigenous women are entitled to enjoy the same fundamental freedoms, the same human rights, as all other people.

Ten years ago, the United Nations adopted the Declaration on the Rights of Indigenous Peoples. The Declaration affirms the rights of indigenous peoples and is a human rights benchmark for all countries. Article 22 of the Declaration calls on countries to ensure that “indigenous women and children enjoy the full protection and guarantees against all forms of violence and discrimination.” The Declaration also affirms indigenous peoples’ rights without discrimination to access social and health services, just and fair procedures for resolving conflicts with states and other parties, and effective remedies for infringements of their individual rights. (Arts. 24(1), 40).

Violence against indigenous women is a human rights violation. It is a tragedy whenever and wherever it occurs. It is not acceptable that indigenous women continue to endure extreme rates of rape, assault, and murder, and corresponding lower rates of law enforcement, prosecution, and punishment of their abusers, just because they are indigenous. Countries must meet their obligations under international human rights law, and they must ensure meaningful access to justice and protection for all women everywhere including the most vulnerable—indigenous women.

*Jana L. Walker, Cherokee/Loyal Shawnee/Delaware, is a senior attorney for the Indian Law Resource Center, a nonprofit law and advocacy organization in Helena, Montana that provides assistance to Indian nations and other indigenous peoples who are working to protect their human rights, lands, resources, environment, and cultural heritage. She is the director of the Center’s Safe Women, Strong Nations project, which works to end violence against indigenous women and girls.

A photo taken by Charandev Singh shows a close up of a banner painted by Ms Dhu's family. In the centre is a printed poster with the same design featuring a photo of Ms Dhu that people wore on their shirts. The main text reads 'Forever Young'. Flowers are painted around the banner. Messages are written in marker from friends, family and community.


Anger, revulsion and heartbreaking futility – those are the feelings that one is left with after reading the Coroner’s record of investigation into the death of Miss Dhu. She was failed by virtually every person who was responsible for keeping her safe. Watching the CCTV footage of her final hours is all the more harrowing because Miss Dhu was unfailingly polite to those who treated her with callous indifference.

I cried when I read that Miss Dhu was a bright student who had trained to become a receptionist. She once played netball, had learnt Aboriginal dances, and was described by her family as very affectionate. Most 22-year old Australians aspire to rewarding jobs, travel and building a community of friends. Miss Dhu, however, was in police custody because she was poor. As she could not pay fines that amounted to $3,622.34, Miss Dhu was compelled to serve four days’ imprisonment. During that time, she was subjected to treatment that was described by the Coroner as ‘unprofessional and inhumane’. Less than 48 hours after she was taken into police custody, Miss Dhu passed from this world without so much as holding the hand of a cherished relative, or being told that she was loved.

Over a quarter of a century ago, the Royal Commission into Aboriginal Deaths in Custody provided us with an opportunity to bring an end to the tragedy that fell upon 99 Indigenous people. They were people who left behind families, friends and dreams that would never be realised. For the most part, however, the Commission’s recommendations have only gathered dust. Politicians who want to stay in power must be able to read the electorate. Their policies and inane slogans are responsive to the desires and fears of their constituents. If Australians cared about Miss Dhu and her story, then our politicians would be compelled to take action. And therein lies the most fundamental question of all – When will Australians place value on the lives of Aboriginal people?

Nicole Watson is a member of the Mununjali and Birri Gubba peoples. She is employed as a senior lecturer in the Faculty of Law, University of Sydney.

First published by the First Nations Deaths In Custody Watch Committee.

Nine people stand in a row in front of a limestone wall that forms part of the Fremantle Roundhouse. They hold placards naming the deaths of seven people as a result of Australia's border policies.
Call to Account, Fremantle, 2015. Photo: Chris Lewis.


In the lead up to Human Rights Day, Researchers Against Pacific Black Sites (RAPBS) compiled a list of charges calling the Australian state to account for its failures to uphold international human rights conventions and treaties such as the Rights of the Child, the Convention against Torture and the Refugee Convention.

RAPBS, with support from RRAN WA and RAC Melbourne, were joined by people from various walks of life to stage readings of the list of charges in Melbourne, Sydney and Fremantle.  The readings called to account the Australian government for perpetrating  human rights violations against asylum seekers and refugees, both in detention centres and in the precarious conditions people are forced to endure under other unlivable terms, like the temporary protection visas.

These readings were combined into a short film for international circulation, produced by Steve Thomas.

Further information: RAPBS Call to Account 2015

The Call to Account actions are also discussed in ‘Between Spectacle and Secret: The Politics of Non-Visibility and the Performance of Incompletion‘ by Suvendrini Perera and Joseph Pugliese, Chapter 4 in Visualising Human Rights edited by Jane Lydon.


Flyer for Deaths in Custody forum, it reads 'Public Forum. Institutional Racism Kills. From John Mr Ward. When: 16 September, 6-9pm. Venue: Perth Town Hall (Cnr Hay and Barrack St, Perth). Unequal justice. Disposable lives. What must change?. Guest speakers: Mark Bin Bakar, Helen Corbett, Dot Henry, Les Malezer, Gavin Mooney & Charandev Singh. Ward family members will also be present.' It includes a photo of a woman holding a banner that reads 'Wheres The Justice' and logos of the Deaths in Custody Watch Committee WA, Amnesty International and Curtin University of Technology.

A photo of a woman standing and speaking at a public event is collaged on top of a photo of two women sitting behind tables, speaking on a panel. In the background a banner is draped over a board. It reads 'Immigrant Women's Speakout'.

At the culmination of the Australian Federal ‘race election’ campaign, migrant, refugee and Indigenous women hosted an alternative ‘great debate’ to discuss issues of racial and sexual violence from their perspectives. The forum was held at the University of Technology, Sydney on November 8, 2001, two days before a bitterly-fought election returned a conservative government to power.

The election campaign was waged against a backdrop of security fears about terrorism, refugees and ‘ethnic crime.’ In this forum, women from Indigenous and non-English speaking and backgrounds discussed how the climate of escalating hostility and fear has impacted on their lives.

“The race election we had to have has effectively silenced the voices of women, in particular migrant and refugee women and Indigenous women on issues of sexual and racial violence,” said Ms April Pham, spokesperson for Women Reporting Violence Organising Committee.

“The half-day Forum was also anopportunity for a critique of the historical, systematic, and continuing violence waged against women of ‘difference’ and for discussions about the representation and misrepresentation of racial and sexual violence”.

The Forum commenced with Indigenous and Indigenous women leading a Remembrance ceremony to honour the many women, children and men who have died as they sought asylum and freedom.

This was followed by two panels:

I: Challenging The Media: where refugee, migrant and Indigenous women will address the issues about how women’s voices are silenced during times of war by media and political pressures.

II: Women speaking back to violence: in which women spoke of their own experiences, indigenous, immigrant and refugee, of repression and silencing and the weapons to fight back.

The Forum was organised by Immigrant Women’s Speakout Association of NSW; by We Who Believe in Freedom: End Racialised Punishment, by X-Text,  by UTS and by individual activists.

This Forum was organised to hear from the silenced voices of women, in particular Indigenous, refugee and migrant women in relation to issues of sexual and racial violence as well as to critique the historical, systematic, and continuing violence waged against women of ‘difference’ and to foreground  discussions about the representation and misrepresentation of racial and sexual violence.

Check the media release and the program of the forum.

Forum and media panel contributions: 

Mahboba Cina:  Afghan Women’s Group

Omeima Sukkarieh & Mia Zahra: Silence that Speaks and Dreams that Cry!

Jane-Corpuz-Brock: Migrante Australia

Wendy-Bacon: Independent Centre for Journalism


Women reporting violence tape 1

Women reporting violence tape 2

Women reporting violence tape 3

Organizing Collective: April Pham, Christina Ho, Heather Goodall, Lena Nahlous, Paula Aboud, Suvendrini Perera




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Aboriginal and Torres Strait Islander viewers are respectfully advised that this website contains images of and references to deceased persons.

All viewers are respectfully advised that the site contains images of and references to the deaths in custody of Indigenous peoples, Black people and refugees that may cause distress.