Dispatch Perth


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.


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