Dispatch Perth - Ali Jaffari's Inquest


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.


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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.