Inquest into the death of Azhar Abdul

CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Azhar Abdul Hearing dates: 26 May 2023 Date of findings: 26 May 2023 Place of findings: Lidcombe Findings of: Magistrate Kennedy Deputy State Coroner Catchwords: CORONIAL LAW – Cause and manner of death, death in custody, intentional self-inflicted injury, care and treatment, mental health considerations, concerns of threats in custody, transfer of prisoners who have received threats.

File number: 2022/00062168

Representation: Mr Kai Jiang, Advocate Assisting Commissioner for CSNSW – Janet de Castro Lopo, DCJ Justice Health and Forensic Mental Health Network – Katharine Guilford Findings: I make the following findings pursuant to Section 81 of the Coroners Act 2009 (NSW): The identity of the person who died The person who died was Mr Azhar Abdul Date of death 2 March 2022 Place of death Bathurst Correctional Complex Bathurst New South Wales Cause of death Mr Azhar Abdul died as a result of hanging Manner of death The death was intentionally self-inflicted Recommendations: I make no recommendations pursuant to Section 82 of the Coroners Act 2009 (NSW)

1. This is an Inquest into the death of Mr Azhar Abdul. This is a mandatory inquest pursuant to section 27 of the Coroners Act 2009 (the Act), as Mr Abdul was in custody at the time of his death. The legislation requires the State Coroner or a Deputy State Coroner to hold an inquest to ensure that proper care and treatment is extended to those who are not free to make their own choices and are reliant on the State to provide medical treatment for them.

2. Section 23 of the Coroners Act 2009 allows a senior coroner jurisdiction to hold an inquest concerning the death of a person if it appears that the person died within lawful custody.

Section 27 of the Act makes the holding of an inquest mandatory in this case.

3. Inquests are not adversarial, but inquisitorial. The purpose of an inquest is not to attribute blame or punish anyone, but rather to investigate how and why a person died, and to find mechanisms, if possible, to stop preventable deaths. Section 81 of the Act requires the identity of the person who died, the date and place of their death be found. Importantly the inquest should also disclose the cause and manner of the person’s death.

Background to the life of Mr Abdul

4. Mr Azhar Abdul was born on 22 March 1995. He was 26 years of age at the time of his death. He was survived by his elder brother and their mother. Mr Abdul was raised by his mother alone. His parents separated in July 1994, and he had no contact with his father.

5. Mr Abdul was schooled on the Central Coast of NSW until the completion of year 10. He then started a carpentry apprenticeship which he did not complete. He was never married and did not have any children.

6. On 25 May 2016, Mr Abdul was arrested with five co-offenders and was charged with supply of prohibited drugs. He was convicted on 17 November 2017 and received a term of imprisonment of 12 years and 6 months with a 9-year non-parole period. This was his first time in custody. He was housed at various correctional facilities within NSW since his incarceration. He managed well in the custodial setting and embraced opportunities to work, study and exercise. He obtained certificates in personal training and cooking whilst he was placed at Macquarie Correctional Centre.

7. In 2021, Mr Abdul was deemed suitable to participate in the Defence Community Dogs program at the Honour House in Bathurst Correctional Complex. The program trains dogs to act as support companions for veterans. This was considered to be a privileged position amongst inmates as it provides more freedom, flexibility and opportunities to be in the community. The dogs assigned to the inmates also live with them. This is evidence of how Mr Abdul was viewed within the system, and how far he had progressed while in custody.

8. On 25 June 2021, Mr Abdul was transferred to the Bathurst Correction Complex. He was reclassified to minimum security. He was initially housed in the X wing and then moved to Honour House on 28 June 2021 where he remained until 27 February 2022. He was assigned a dog named “Opal” for the Dogs program. He enjoyed the program and his time with “Opal”.

9. Since entering custody, Mr Abdul was introduced to his now ex-partner through mutual friends. She resided in Queensland and the pair started with communication via letters and gaol calls which eventually grew into a formal relationship. His ex-partner visited Mr Abdul for the first time in April 2021 when he was housed at the Macquarie Correctional Centre. The relationship had its challenges however it appeared that they were making serious future plans together. In December 2021, the pair broke up for a few days. The reason was unknown. Mr Abdul was noticeably affected by this at the time.

10. Sometime in 2022, arrangements were made for Mr Abdul’s ex-partner to move down from Queensland on 18 March to live with his mother in preparation for his eventual release on parole. On 25 February 2022, however, Mr Abdul told his ex-partner via video call, not to make the move for her own protection. He would not elaborate further on the reason. He was described to be erratic during the call. He ended their relationship and cut all communication with her. He became reserved and declined to disclose details.

11. On 27 February 2022, Mr Abdul requested to be removed from the Honour House immediately and sought protective custody which was immediately authorised. No reason was initially given for this sudden request. Risk assessments were conducted on the same day and again on the following day. Mr Abdul repeatedly guaranteed his own safety and denied any intention to self-harm. He was also interviewed by Corrective officers between 28 February and 1 March 2022, during which he explained that he owned a significant debt to Outlaw Motorcycle Gang members. However, he denied being threatened or stood over in the Honour House. He would not provide any other information regarding his request for protective custody. Mr Abdul was placed into protective custody in Cell 16 of the D-Wing Bubble pending further re-classification assessments before transfer to another correctional centre.

12. On 2 March 2022, Mr Abdul was found hanging by a ligature under the basin within his own cell. Despite resuscitative efforts, he could not be revived and was declared deceased at 12:33pm.

13. At the time of his death, Mr Abdul was in lawful custody held at the Bathurst Correctional Complex pursuant to the sentencing warrant dated 17 November 2017.

Medical History

14. Mr Abdul was generally healthy apart from possible gastrointestinal issues. Whilst in custody, he had minimal contact with Justice Health. There was no history of mental health. The last time he saw a psychologist was on 18 May 2017. His case was closed on the same day without further referrals as no mental health issues were identified.

Events leading up to death

15. Evidence suggests that Mr Abdul was paranoid about his ex-partner’s fidelity and felt insecure about their relationship. His ex-partner alluded to him giving her an ultimatum at some point after their breakup in December 2021. This may have been the catalyst for the arrangement for her to move to reside with his mother on 18 March 2022.

16. In the week before Mr Abdul’s death, he was observed to be distressed about something and appeared to be depressed. However, he kept the issues to himself and did not share with other inmates. At the same time, it appears that he changed his mind about his expartner’s move and was actively against the idea. He said that this was for her own protection. Despite this, he still said he loved her.

17. On 25 February 2022, Mr Abdul called his ex-partner. He was described to be erratic during the call and told her not to move to the Central Coast. He said that there were things that he cannot explain over the phone. Mr Abdul then ended their relationship.

Subsequently, she sent three letters, dated 25th, 27th and 28th of February 2022 pleading for him to reconsider their relationship, but it is uncertain if he ever saw or read those letters.

18. Mr Abdul’s final phone calls made were to his mother between 25 and 27 February 2022.

He informed his mother of his breakup with his partner and that he had ceased all communication with her. He told his mother that he was “not in a good way”. He also asked his mother to move her residence for her own protection. There were veiled suggestions of external factors at play which he refused to elaborate further over the phone due to his location.

19. Sometime after lunch on 27 February 2022, Mr Abdul approached a corrective officer and requested immediate removal from the Honour House. There were no other inmates in the area at the time. Mr Abdul stated that he needed to leave Honour House before others return. He was observed to be jittery, anxious and when pressed he said that he needed to get out due to external problems. He refused to be transferred to another minimumsecurity wing within Bathurst Correctional Centre as he believed that the problems would follow him there.

20. After speaking with other inmates, despite Mr Abdul’s confirmation that he had no intent to harm himself, the corrective officer still expressed concerns regarding Mr Abdul’s mental health to the Functional Manager via email and requested placement in an observation cell with CCTV. The Functional Manager formed the opinion that Mr Abdul may attempt to escape when he requested to leave the Honour House.

21. Mr Abdul was taken to the reception area where he was spoken to. He again denied any mental health issues and declined any assistance. He was assessed to be future orientated with plans to progress his classification and intention to obtain work releases. After considering Mr Abdul’s records and the concerns raised by the corrective officer, a protective custody direction was completed by the Functional Manager. Mr Abdul was placed in isolation in cell 16 of the D-Wing Bubble to remove him from any current threats until completion of risk assessments and pending re-classification.

22. Of note, the same corrective officer reported that, after transporting Mr Abdul away from the Honour House, he was approached by two inmates who he said had reputations as “pod bullies” at both the X wing and the Honour House. They were also known to have associations with Outlaw Motorcycle Gangs. Mr Abdul’s location was not disclosed despite repeated demands from these two inmates. However, it is noted that Mr Abdul denied ever being stood over or threatened by other inmates.

23. On 28 February 2022, a risk assessment and interrogation of Mr Abdul’s reasoning for leaving the Honour House was conducted by another Functional Manager. Mr Abdul said that he was in debt to “bikies”. This same information was provided to a third Functional Manager on the same day and again on 1 March 2022, during which Mr Abdul expanded that he borrowed $12000 but the money had been taken. He would not disclose the name of whom he owed money to. Further, when pressed in relation to whether he was stood over or threatened in the Honour House, he stated that he was “not going to be a dog”.

He repeatedly confirmed that he did not have any thoughts of self-harm or suicide. As such Corrective Services concluded that a health assessment was not required given Mr Abdul’s guarantee of self-safety and lack of prior mental health history.

24. On 2 March 2022, industrial action was initiated by Corrective Services staff. All inmates at Bathurst Correctional Centre were locked down. Head checks were still conducted, and inmates were still provided their meals and basic needs.

25. At 8:38am on 2 March 2022, a head check was conducted at Block D. When checked, Mr Abdul asked the corrective officer if it was “lock in” that day. That was the last time he was seen alive.

26. At 12:12pm on the same day, corrective officers attended cell 16 to deliver lunch. The cell was dark, and Mr Abdul did not respond when his name was called. Upon entering, Mr Abdul was located hunched over with his head underneath the sink suspended by a ligature. He was cold and stiff to touch. Corrective officers immediately called for medical assistance. Mr Abdul was cut down from the ligature and placed on the ground. Corrective officers commenced CPR which was taken over by the attending Justice Health staff.

27. At 12:19pm, resuscitative efforts ceased, and Mr Abdul was declared deceased by the Justice Health staff. This was confirmed at 12:33pm by the attending ambulance officers.

Investigation following his death

28. Following Mr Abdul’s death, cell 16 was cleared and secured. NSW Police were contacted.

Mr Abdul’s identity was confirmed via fingerprint. CCTV footage between 1st and 2nd March 2022 was obtained and reviewed. The camera in Block D covered the common area outside the cells. No one was seen to enter or exit cell 16 after it was locked by a corrective officer at the end of the head check around 8:30am on 2 March 2022 and before Mr Abdul was found unresponsive inside his cell.

29. Cell 16 was forensically examined and searched. The duress alarm inside the cell was checked and was functional. There was no record of activation after Mr Abdul moved in.

30. The cell was fitted with two doors, an external solid steel door and an inner barred metal door. Inside the cell was a double bunk bed to the left and a set of metal shelves to the right. The top bunk appeared to have been occupied by Mr Abdul. Amongst other things, there was a plastic rubbish bag on the bed which had strips of torn bed linen consistent with the ligature material used.

31. A window covered with steel grille was located at the top of the far wall in the cell.

Another ligature was tied to the grille. It was believed that this was used by Mr Abdul for his first suicide attempt which snapped. He then tied a new ligature to the supporting bracket on the bottom of the sink basin where he was found.

32. A piece of paper was located in the toilet opposite to the sink. There was writing on the paper which was crossed out. A love heart was drawn on the paper with the words “Mum & Brother xxx” written underneath. It appears that Mr Abdul tried to leave a suicide note to his family but decided ultimately to cross it out and dispose of it in the toilet.

33. Police interviewed inmates at the Honour House who were considered Mr Abdul’s close friends in custody. His mother and ex-partner were also spoken to by Police. Their evidence is summarised below.

Summary of the evidence

34. Inmates described Mr Abdul as someone who presented a solid front but kept issues to himself. He would often be fixated on one thing. He used the gym often relieve stress.

35. On 25 February 2022, Mr Abdul was observed by inmates to behave strangely after a phone call. One of the inmates heard him talking about a $10000 figure. Inmates assumed that he was upset due to another relationship breakdown. He was known to be serious about his relationship. However, inmates believe the fact that Mr Abdul was in custody and had no control over issues happening on the outside was an obvious stressor to his mental wellbeing. Inmates stated that when he broke up with his ex-partner the first time in December 2021, he was not himself for over a week until they reunited. Inmates tried to console him, but he declined to share his troubles and did not accept their help.

36. On 27 February 2022, when Mr Abdul left Honour House, he left all his properties behind.

Inmates were concerned about his change in mood and behaviour and raised their concerns with corrective officers. They asked for Mr Abdul to be monitored and provided mental health assistance. When asked, however, Mr Abdul stated that he was fine.

37. According to the inmates, Mr Abdul was not known to have any debts, or issues with drugs or gambling. They did not believe that he would take his own life.

38. Mr Abdul’s ex-partner confirmed that she was introduced to him through a mutual friend.

They began as friends and communicated via letters and gaol calls. The friendship eventually became a relationship. In April 2021, she visited Mr Abdul at the Macquarie Correctional Centre and met him for the first time. They had plans for a future beyond Mr Abdul’s imprisonment. There was an arrangement on 18 March 2022 for her to move to live with his mother. She denied knowledge of any debts owed by Mr Abdul. She also had not heard him mention having any issues with other inmates.

39. The ex-partner stated that Mr Abdul acted strangely in the week leading up to his death.

He said that he loved her but asked her not to make the move as arranged. He said that it was for her own protection. This was repeated on 25 February 2022. Mr Abdul said that there were things he could not explain over the phone. She confirmed that he ended their relationship during that call and that was the last time she spoke to or heard from him.

40. Mr Abdul’s mother provided some background information about him. She knew about the breakup. She was unaware if he had any mental health issues. However, she believed that his relationship had caused him significant amounts of stress and anxiety which was exacerbated by Covid restrictions.

41. Police obtained and listened to all recorded phone calls made by Mr Abdul from December

42. Most of the calls were to his ex-partner and mother. Of note, the last phone call to his ex-partner was on 5 February 2022. Further contact with her since that date were made via video call which were not recorded. The last two calls to his mother were on 26 and 27 February 2022.

43. An analysis of the call recordings confirms that Mr Abdul was paranoid about his expartner’s fidelity and doubted her interest in him. This is corroborated by information from inmates that he felt insecure about his relationship as he had no control over what happened outside of gaol.

44. Investigation further discovered that there was an unmonitored mobile phone circulated within the Honour House. It appears that Mr Abdul has previously used this phone to communicate with both his mother and ex-partner and maybe others in the community.

Mr Abdul’s mother was also first informed of his death through information from this phone. No further evidence was provided or able to be obtained regarding this phone.

44. A review of Mr Abdul’s Corrective case notes in the 12 months prior to his death, showed positive reports in relation to his work ethic and behaviour. He settled well into the Defence Dogs Program. There had been no adverse incidents and no active alerts of relevance. No issues were identified from the corrective case management and warrant files. All involved corrective officers were interviewed or spoken to by both Corrective Services investigator and the Police officer in charge.

45. The investigation concluded that corrective officers took all reasonable actions in accordance with the relevant policies to remove Mr Abdul from any perceived threats at his own request. Further, it appears that concerns regarding his mental health were reasonably investigated and acted upon by Corrective Services. In Mr Abdul’s case, it was taken into consideration that he had no history of self-harm or suicide, and he was future orientated without any expression of concern to his safety. He was therefore not considered to be an inmate at risk in accordance with the Custodial Operations Policy and Procedures. As such, it appeared that Corrective Services focused on ascertaining the reason why Mr Abdul wished to be moved to enable an effective re-classification and necessary transfer.

46. Justice health medical records were produced and reviewed. The records were unremarkable apart from the required inmate screening assessments. Mr Abdul’s last medical appointment was on 18 November 2019 for minor issues. The last Health Problem Notification Form completed was in August 2020 and recommendation was made for normal cell placement. The last reception screening assessment in June 2021 when Mr Abdul was transferred into the Bathurst Correctional Complex did not identify any issues.

Autopsy Report

47. A post-mortem examination was conducted. The resulting Autopsy report found the direct cause of Mr Abdul’s death was in keeping with hanging. The toxicological analysis did not detect any alcohol, drugs or other substances of concern. No injuries apart from fracture to the hyoid bone were found. The fracture was not uncommon and was reported in 27% of death by hanging.

48. There were no suspicious circumstances in relation to Mr Abdul’s death. There is no evidence indicative of any third-party involvement in his death.

Issues raised regarding Mr Abdul’s death:

49. Since Mr Abdul’s death, his mother reported receiving the following information: a. By a journalist, indicating that a “gaol warden” had requested for Mr Abdul to be placed in a “mental health unit” which was denied by a “manager” who has since transferred to another gaol as a disciplinary measure, and b. By an inmate, whose identity is undisclosed to Police, that corrective officers had spread rumours about Mr Abdul owing a large debt to “bikies” which was the reason why he took his own life.

50. Based on this information, Mr Abdul’s mother raised the following concerns in relation to his care and treatment in custody: a. That there was a lack of appropriate mental health care and support provided since his move from the Honour House, and b. That there was limited supervision and lack of CCTV monitoring, after his placement in Block D.

51. Mr Abdul’s mother believed that Corrective Services covered up negligence in relation to his care by fabricating rumours about him owing a significant debt to Outlaw Motorcycle Gang, and that senior corrective officers had failed to place him under observation as requested and despite concerns raised regarding his mental health.

52. His mother also, understandably, questioned whether the industrial action taken by corrective officers on 2 March 2022 impacted on their ability to prevent Mr Abdul’s death.

Analysis of the evidence

53. The industrial action was directed to all non-commissioned corrective services officers and commenced at 9:30am on 2 March 2022. There were limited staffing at the Bathurst Correctional Complex due to the strike. However, inmates were still monitored by the remaining commissioned officers and were provided basic needs. When Mr Abdul was last sighted, there were no signs of concern. There were no predicators to his actions.

54. Secondly, regarding the information from the journalist, that a gaol warden had requested for Mr Abdul to be placed in a mental health unit which was denied by a manager who has since transferred to another gaol. This information appears to be consistent with the evidence available, although there is no evidence to suggest that the transfer of the manager was as a result of any disciplinary measure. This evidence supports that there were concerns for Mr Abdul, and they were raised by a corrective officer.

55. However, the decision by corrective services not to place Mr Abdul in an observation cell or refer him to the Risk Intervention Team was based on the following facts: a. The lack of any prior history of mental health issues, self-harm or suicidal ideation or attempts, recorded or expressed.

b. Mr Abdul’s repeated guarantee for his own safety and denials of self-harm or suicidal thoughts after multiple interviews between 27 February and 1 March 2022 by various senior corrective officers.

c. The lack of any evidence to suggest that requests were made by Mr Abdul for mental health assistance.

d. The fact that Mr Abdul was actively seeking protection, attempting to protect himself and his family from the harm that he feared.

e. Mr Abdul’s attempts to protect himself from threats, in an attempt at selfpreservation.

56. It appears on the evidence that there is reason to suspect that Mr Abdul was being threatened. The evidence included: a. Information provided by Mr Abdul during the risk assessment on 28 February 2022 where he first disclosed that he owed a debt to “Bikies”.

b. Report from interviews with Mr Abdul, both on 28 February and 1 March 2022, where he provided consistent information regarding the debt. However, Mr Abdul would not disclose who he owed the money to.

c. Information from inmates to Police about overhearing Mr Abdul talking on the phone about an amount of $10000 in the days before his removal from the Honour House.

d. Mr Abdul’s sudden change of mind about his ex-partner’s pre-arranged move down from Queensland and his attempt to convince his mother to move her address, all for their own protection and reasons he cannot explain over the phone. This is indicative of perceived fear of repercussions to his family in the community by someone whom he may have owed the debt to.

e. Mr Abdul’s refusal to be simply transferred to another minimum-security wing within the Bathurst Correctional Complex as he believed that his problems would follow him there. It can be inferred that Mr Abdul perceived threats from within the correctional facility as well.

f. Multiple reports of Mr Abdul referring to external problems or factors when asked why he wanted to be moved from the Honour House.

g. Evidence of demands from two inmates, possibly associated with Outlaw Motorcycle Gangs, to know Mr Abdul’s whereabouts after he left the Honour House.

57. Addressing the concern regarding the lack of mental health support and care after Mr Abdul’s removal from the Honour House and his placement in a normal cell rather than an observation cell as requested by others, it is noted that after efforts by corrective officers, Mr Abdul was never identified as at risk of self-harm or suicide. Despite there being a general concern for his mental health, there was no evidence to suggest that any such concerns amounted to intention to commit self-harm or suicide. Given the repeated guarantees of self-safety, Mr Abdul’s circumstances did not meet the requirement for mandatory referral to the Risk Intervention Team nor was there a need to place him under observation.

58. Relevant policies from Justice Health regarding health assessments of inmates were also obtained and reviewed. As Mr Abdul was moved within Bathurst Correctional Centre, he was neither newly received into custody nor was he transferred between correctional centres. As such, no Reception Screening Assessment or Transfer In and Out assessment, both of which would have included a mental health assessment, was required to be completed when Mr Abdul was moved out of the Honour House and placed into the DWing Bubble.

59. The evidence supports a finding that Mr Abdul suddenly became concerned not only for his own welfare but for his ex-partner and his mother. He raised concerns with his mother and partner. Other inmates noted the changes. He raised the fears with correctional officers. Importantly, given threats of harm were made the footage was viewed and no other person entered or exited his cell during the lock down period.

60. Although it is clear that there were a number of concerning features in relation to Mr Abdul’s behaviour, he did not want to consult in relation to mental health. He did not inform officers nor family that he had any intention of self-harm. I accept that indeed his action of disclosing threats would suggest that he was trying to preserve his own life.

61. After a review of the evidence, I can conclude that unfortunately Mr Abdul did not share his thoughts of self-harm. Corrective Services acted in accordance with policy once he disclosed risk of harm by other inmates in placing him in a one out cell particularly when they did not know who he feared. The circumstantial case is consistent with him being in real fear for himself and his loved ones, choosing to leave a privileged program that he had enjoyed, separating from his ex-partner very suddenly and suggesting he could not speak openly. He told his mother to relocate and reported fears to Corrective officers.

Consistent with those fears, making them appear even more serious he would not disclose names nor details. Independent corroboration of these threats was the interaction between a corrective officer and persons known as standover prisoners demanding to know Mr Abdul’s whereabouts.

62. There was a lack of obvious mental health issues existing. However, Mr Abdul was future orientated, even raising future work release making it difficult to identify any danger that Mr Abdul would self-harm. In fact, he appeared to be acting out of self-preservation in seeking to be moved.

63. There is also evidence that Mr Abdul was emotionally distressed in relation to relationship issues. It is so unfortunate that he did not reach out to anyone to assist him in relation to the details of his fears and feelings. I am satisfied that attempts were made to assist him, but he did not wish to engage.

Acknowledgements

64. Thank you firstly to the family of Mr Abdul for raising concerns that could be addressed through the preparation of the inquest in obtaining the necessary evidence.

65. Thank you to the officer in charge Detective Senior Constable Belfanti for the time and effort that he put into his detailed investigation of this matter.

66. Thank you to Mr Jiang, Coronial Advocate assisting, for a thorough and careful preparation, attention to detail and appropriate submissions made to assist in this inquest.

67. I make the following findings pursuant to Section 81 of the Coroners Act 2009 (NSW): The identity of the person who died The person who died was Mr Azhar Abdul Date of death Mr Abdul died on 2 March 2022 Place of death Mr Abdul died at Bathurst Correctional Complex, Bathurst, New South Wales Cause of death Mr Abdul died as a result of hanging Manner of death Mr Abdul died as a result of intentionally self-inflicted harm

68. I make no recommendations pursuant to Section 82 of the Coroners Act 2009 (NSW).

Conclusion

69. I extend my sincere condolences to the family and friends of Mr Azhar Abdul. I now close this inquest.