Coroner's Finding: ALI Safar

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 22nd day of November 2018, the 1st day of July 2019 and the 8th day of May 2020, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Safar Ali.

The said Court finds that Safar Ali aged 25 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia died at Northfield, South Australia on the 10th day of April 2015 as a result of compression of the neck due to hanging. The said Court finds that the circumstances of his death were as follows:

1. Introduction, reason for inquest and cause of death 1.1. Safar Ali died on 10 April 2015 at the Yatala Labour Prison (the YLP) where he was a remand prisoner. He was 25 years of age at the time of his death. Mr Ali was found hanging in his cell from a ligature made from a bedsheet that was suspended from a shelf in his cell. His death was a death in custody for which an inquest was mandatory.

These are the findings of that inquest.

1.2. Dr Neil Langlois, a forensic pathologist at Forensic Science South Australia, conducted a post mortem examination in respect of Mr Ali’s remains. Dr Langlois’ report1 expressed the cause of Mr Ali’s death as compression of the neck in keeping with hanging. The significant findings at autopsy were a ligature mark on the neck, a fracture of the left superior horn of the thyroid cartilage and petechial haemorrhages of the left and right eyes. As Dr Langlois opines, these findings are all ‘in keeping with’ hanging.

To my mind, and having regard to all of the circumstances quite apart from the 1 Exhibit C2

pathological findings at post mortem, there is no explanation for these findings other than they were in fact caused by hanging. I find that the cause of Mr Ali’s death was compression of the neck due to hanging.

1.3. Aside from some scarring on Mr Ali’s left arm and abdomen, there were no other signs of injury.

1.4. Post mortem toxicology was negative for the presence of alcohol or other drugs in Mr Ali’s system.

1.5. Mr Ali had been an enthusiastic body builder. Dr Langlois describes him thus: ‘The body was that of an adult male weighing (on admission) 76 kilograms and measuring approximately 166cm in length (BMI = 28). He appeared of average but muscularly developed build, well-nourished consistent with the stated age’.

Although not large in stature, I infer that Mr Ali had been a man of considerable physical strength. The photographs of Mr Ali taken after death at the YLP add to that impression. Having regard to his physical prowess it is intrinsically unlikely that Mr Ali’s hanging was carried out against his will by any other persons or persons. For that and other reasons I will mention in due course, I have found that no other person was involved in the incident that led to Mr Ali’s death2.

1.6. Information imparted to investigating police was that Mr Ali was a user of steroids and alcohol. There is no evidence of mental illness, diagnosed or otherwise.

1.7. Mr Ali did not leave a suicide note.

2. Background 2.1. Mr Ali was born on 2 January 1990. It is believed that Mr Ali was born in Afghanistan and emigrated to Australia at about the age of 15 with his brothers and sister.

2.2. On 24 July 2014 Mr Ali was arrested for the attempted murder of his ex-partner with whom he had been in a relationship for about six years. The woman in question apparently wanted the relationship to end due to Mr Ali's alleged controlling behaviour and alleged violent conduct. Having been warned by police to stay away from her address on a number of occasions, he attended at her premises and spoke to her through 2 Exhibit C21b, photograph 49

the front door. Mr Ali's ex-partner alleged that when the conversation concluded Mr Ali entered the premises, pushed her into the bathroom and squeezed her neck until she became unconscious. When the woman regained consciousness Mr Ali had a knife and was stabbing himself, albeit superficially and in a non-life threatening manner. The ex-partner took the knife from him and escaped from the premises. Mr Ali was arrested by police that day. Apart from driving offences, he had never been involved with the criminal justice system. He had never been in prison.

2.3. Due to Mr Ali's self-harming conduct police conveyed him in the first instance to the Royal Adelaide Hospital where he was placed on an Inpatient Treatment Order under the Mental Health Act 2009. However, after further assessment the order was revoked and he was returned into police custody. Mr Ali was charged with attempted murder and was remanded in custody. He would remain in custody from 24 July 2014 until the day of his death. I find that Mr Ali was in lawful custody at the time of his death.

2.4. Mr Ali ultimately pleaded not guilty to the charge of attempting to murder his expartner. At the time of his death Mr Ali's trial in the Supreme Court of South Australia was ongoing. The trial had commenced on 7 April 2015. It was a trial by judge alone.

On Friday 10 April 2015 the trial was adjourned for the delivery of counsels’ closing addresses the following Monday.

3. Mr Ali’s custody 3.1. Once remanded in custody at YLP Mr Ali was admitted into G Division for constant observation. On 25 July 2014 a high risk assessment was conducted and as a result of that assessment he was to be managed in the first instance by the High Risk Assessment Team (HRAT). On that day Mr Ali stated to prison authorities that he had only ever made one attempt to end his life and that this had occurred in the incident involving his ex-partner in respect of which he had been arrested and remanded in custody. He was assessed to have no history of suicide, no psychiatric history and no major life difficulties. Mr Ali exhibited no apparent suicidal ideation, intent or planning. He told correctional services officers that he was adamant that he would not try to harm himself again and that his previous attempt was due to alcohol intoxication. He was assessed as being at medium risk of self-harm and was to be monitored.

3.2. On 28 July 2014 Mr Ali was cleared to leave G Division.

3.3. On 30 July 2014 Mr Ali presented as bright. He engaged appropriately. He had made contact with his brother and had arranged a lawyer. He was able to discuss his relationship in a calm manner. He stated that to assist in maintaining positive focus he had been able to utilise strategies he had employed as a body builder such as willpower.

He was assessed as presenting at a low risk of self-harm. However, it was recommended that he remain on the HRAT list and be monitored for a further week.

3.4. On 31 July 2014 Mr Ali was discussed at a HRAT meeting. He had been presenting well and was assessed as being at low risk of self-harm. It was recommended that he remain on the HRAT list and be monitored for a further week.

3.5. On 6 August 2014 Mr Ali was assessed as being bright and jovial and was engaging well. He denied thoughts of self-harm. He was assessed as being stable.

3.6. On 7 August 2014 subsequent to a HRAT meeting conducted on the same day, Mr Ali was removed from the HRAT list due to a stable presentation and nil evidence of selfharm.

3.7. Thereafter Mr Ali did not exhibit any behavioural issues while in custody. He was regarded as a quiet prisoner and as an avid gym enthusiast and body builder. He maintained an exercise regimen in the gymnasium. He remained in contact with his brother via telephone. He wrote letters, none of which indicated any intention of selfharm. On one occasion he wrote a letter to his ex-girlfriend which was in breach of his interim intervention order and which resulted in further charges.

3.8. While on remand gave no sign to correctional officers or other inmates that he would harm himself. There was no indication of conflict with any other prisoner. He maintained a journal of sorts in which he expressed regret in relation to his former partner.

3.9. On 14 August 2014 Mr Ali was re-accommodated in F Division at the YLP and was required to work in the joinery unit. F Division at the YLP is used to house medium to low security male prisoners who are either on remand or are of sentenced status. It is described as a working Division where prisoners are not on HRAT management and must be able to demonstrate adherence to prison rules and a willingness to work. At all material times Mr Ali was accommodated in a single cell in F Division.

3.10. As indicated earlier, on 7 April 2015 Mr Ali’s trial commenced in the Supreme Court of South Australia. Both defence and prosecuting counsel in the trial have provided to the inquest statements in which they reveal that they had no concerns in relation to Mr Ali’s welfare during the course of the trial. Mr Ali would have been returned to YLP after each day of the trial, including on Friday 10 April 2015 which was the day of his death.

4. The circumstances of Mr Ali’s death 4.1. Following the conclusion of court proceedings on Friday 10 April 2015 G4S prison escorts returned Mr Ali to the YLP. G4S escorting members noticed nothing out of the ordinary concerning Mr Ali. On arrival at YLP he was escorted to his accommodation in F Division.

4.2. Having returned to F Division, Mr Ali in due course entered the cell of inmate Darcy Brooks. The time was about 5pm. This was at a time when prisoners in the Division had yet to be locked down in their cells, but could still associate and enter each other’s cells. Prisoners were also permitted to remain in their own cells with the door unlocked.

4.3. In his statements3 Mr Brooks asserts that he and Mr Ali had become ‘pretty good mates’.

He described Mr Ali as having been a ‘good bloke’ who was gregarious, well-liked within the unit and who was ‘never really down in the dumps’. Mr Brooks states that he knew that Mr Ali was undergoing his trial and was stressed about it, including about the fact that he had seen his ex-partner again at court. He had also been upset about incriminating evidence that had been given by a certain witness which he said was false.

Mr Brooks said that Mr Ali was down about the trial and was not his usual self, although he did not give any indication that he was so down that he would hurt himself.

4.4. When Mr Ali entered Mr Brooks’ cell after court on the Friday, he was in possession of a copy of The Advertiser newspaper. He was extremely upset and stressed about an article which concerned his trial. He continually complained about it. In his statement4 Mr Brooks asserts that Mr Ali kept reading it and re-reading it and going on about it to the point where Mr Brooks told him to stop reading it as it was ‘doing his (Mr Ali’s) head in’. Eventually Mr Brooks took the newspaper away from Mr Ali. The article in question was tendered to the Court. I have read the article. The article is short, not 3 Exhibits C4 and C4a 4 Exhibit C4a

especially prominent and is not in any sense inflammatory. It reports the evidence as it was apparently given. It does portray Mr Ali in an unfavourable light, but only because of the nature of the allegations against him. It is not in any way prejudicial. One aspect of the article that Mr Ali did specifically complain about was its reference to the witness’ evidence that he maintained was false. Evidence provided to this inquiry by participants in Mr Ali’s trial suggested that Mr Ali had been visibly distressed during the testimony given by the witness but had later assumed his usual demeanour. The witness’ evidence as reported in the article was to the effect that several days before the incident involving his ex-partner, and in respect of which he was currently on trial, he had attempted to obtain a handgun from a friend and had told him that he was going to be in the paper and the news. The Advertiser article had fulfilled that prophecy and no doubt the irony of that would not have been lost on Mr Ali, but of course not in a good way. Mr Brooks asserts that he believed the article was what ‘tripped (sic) him over’ and led Mr Ali to do what he ultimately did that evening.

4.5. Later at about 6pm Mr Brooks went to Mr Ali's cell and looked through the trap to see what he was doing. Mr Brooks believed Mr Ali was praying at the time and, out of respect, left him alone. At about 7pm Mr Brooks heard the guards calling out the prisoner count that customarily took place at that time. Inmates were required to stand outside their cell during this process. Mr Ali did not appear. Mr Brooks noted that Mr Ali had not come out of his cell and that his door was closed.

4.6. Mr Brooks and other prisoners yelled at Mr Ali to come out of his cell but there was no response. Mr Brooks and another prisoner, Mr Bowman, looked into Mr Ali's cell and found him hanging. The ligature was a bed sheet. Mr Brooks went to his aid and prison guards attended to assist.

4.7. A correctional officer by the name of Stephane Nucci found Mr Ali hanging from a bedsheet that was suspended from a shelf in the cell. Mr Ali was released from the ligature. He was cold to the touch and non-responsive. A code black was called over the radio. Other correctional officers attended at the cell and CPR was performed.

Nursing staff attended and took over the process of CPR.

4.8. The South Australian Ambulance Service were called. Ambulance officer Erin Tucker stated that upon arrival she noted that CPR had been performed and a defibrillator had been attached. Mr Ali exhibited no signs of respiration nor pulse. Mr Ali was moved

from the cell to the main area for better access. CPR continued and an IV line was inserted. A second ambulance crew arrived to assist. Mr Ali failed to respond to resuscitation. At 7:43pm a decision was made to cease CPR. Mr Ali had been in asystole during the entire time he had been treated. There is no suggestion other than that the resuscitative efforts of corrections and nursing staff and the paramedics were adequate.

5. Police investigation and conclusions 5.1. Mr Ali’s death was thoroughly investigated by SAPOL. The investigation was conducted by Detective Brevet Sergeant Drew Bynoe of the SAPOL Police Corrections Section. Mr Bynoe has provided a comprehensive report in relation to the circumstances of the death of Mr Ali5. In that report he expressed certain conclusions.

I agree with those conclusions.

5.2. In particular I have found that no other person was involved in Mr Ali’s death. In his report Mr Bynoe has indicated that the police investigation did not uncover any evidence of criminal conduct on the part of any person which would lead to the laying of criminal charges in respect of the death of Mr Ali. My conclusion that no other person was involved in Mr Ali’s hanging is reinforced by my viewing of CCTV footage that depicted activities in F Division on the afternoon of Friday 10 April 2015.

Although the camera was not directed towards the door of Mr Ali’s own cell, it is directed towards the cells of other prisoners and it captured, from time to time, Mr Ali and his activities both in respect of the Division generally and also in respect of his interaction with other prisoners. The CCTV corroborates Mr Brooks’ evidence in all material respects. Mr Ali can be seen in the CCTV footage to be in possession of what appears to be a newspaper and to enter Mr Brooks’ cell and spend some time within it.

The one salient feature from the CCTV footage is the calmness within the Division and in particular the calm demeanour of all prisoners depicted within it. There is no hint of aggression or any agitation on the part of any particular individual depicted in the footage. This has led me to conclude that it is highly unlikely that any aggressive, violent or agitated activity took place in the Division that afternoon, and in particular in the period leading up to approximately 7pm when Mr Ali’s body was located. The Division appears to be in a relatively confined area. Had Mr Ali been attacked by any other person it is inconceivable that he would not have raised the alarm and have been 5 Exhibit C22a

heard. I have already referred to Mr Ali apparently being a person of considerable physical prowess. There were no injuries in respect of his person other than those associated with the act of hanging. I am of the opinion that no other person was involved in his hanging. I so find.

5.3. I also find, as has Mr Bynoe in the course of his investigation, that Mr Ali’s hanging could not have been predicted or prevented. Although he had demonstrated some selfharming behaviour during the course of the incident involving his ex-partner, he had been adequately assessed and monitored in the initial stages of his custody at the YLP.

Thereafter he had not given any hint that he harboured a negative frame of mind. His demeanour throughout if anything suggested the contrary. The assessment that he be placed in a working environment in F Division was a reasonable assessment. His being placed in a single cell was also not unreasonable. He had been accommodated in F Division for several months during which he had given no indication that he was at risk of self-harm.

5.4. In my view Mr Ali was acutely affected by the circumstances surrounding his ongoing trial. Although he had exhibited some distress during the course of the trial, none of it was unusual in the sense that it provided any hint of potential self-harm. Mr Ali was particularly distressed by an article in The Advertiser that described certain evidence in his trial which, rightly or wrongly, he claimed was false, but he does not appear to have shared that with corrections staff. Mr Ali’s act of self-harm appears to have been an impetuous one and one that was ill-considered. However, the likelihood of Mr Ali being convicted of an offence that would have seen his further incarceration would no doubt have been on his mind. To my mind this explains his actions. I do not believe that any person could have foreseen the action that Mr Ali took in respect of his own life.

5.5. Although Mr Ali’s act appears to have been an impulsive one, when one has regard to its lethality I have little doubt that Mr Ali intended to end his own life. I so find.

6. Recommendations 6.1. Pursuant to section 25(2) of the Coroner’s Act 2003 I am empowered to make recommendations that in the opinion of the Court might prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the inquest.

6.2. In this inquest it appeared to me that there were two issues that might well be the subject of change and therefore be the subject of recommendation from this Court. I speak here of two issues that have received coronial attention in the past, namely ongoing prisoner stress screening and hanging points in cells.

6.3. Ongoing prisoner stress screening Mr Ali’s death occurred on 10 April 2015. His death occurred after he had been returned to the YLP following what he no doubt perceived was an unfavourable experience in court. His acute frame of mind was complicated by his reaction to The Advertiser newspaper article about his case. Since Mr Ali’s death this Court has heard an inquest into the circumstances of the death of a prisoner, John Costi6, that occurred in the Adelaide Remand Centre on 27 November 2013. Mr Costi died by way of hanging. In that inquest the Court revisited the issue of occasional prisoner stress screening that might be conducted when a prisoner experiences an adverse event in his life, particularly as it might relate to court proceedings. Evidence was given on behalf of the Department for Correctional Services in the Costi matter as follows: 'The implications for ongoing risk screenings occurring for all prisoners at the ARC and other remand prisoners would be impracticable and resource intensive. This is because regularly screening would be required for all types of escorted leave including when returning from court (including the Family Court and the use of Video Conferencing facilities), police escorts, medical appointments, compassionate leave or transfers. I am not aware of this practice occurring in any other correctional jurisdictions.' 7 Nevertheless, evidence was also given in that inquest that the relevant Standard Operating Procedure had recently been reviewed and that there was a draft amendment in existence that would mandate correctional officers to be vigilant for any signs of distress when prisoners return from court. Subsequently, as revealed in the affidavit of Tracy Michelle Watkins the General Manager of YLP tendered to this inquest8, the relevant Standard Operating Procedure which is SOP90 was amended. Paragraph 3.3.9 now stipulates as follows: 'Correctional Officers are to be vigilant for any signs of distress when prisoners, particularly HRAT prisoners, return from any escort, including but not limited to:

(a) Video conference in court;

(b) Police escorts;

(c) Medical appointments, 6 Inquest 2/2017 - Finding delivered 17 January 2018 7 Inquest 2/2017 - Exhibit C46, paragraph 7.8 8 Exhibit C26

(d) Compassionate leave;

(e) Court or Parole Board; and

(f) Transfers from other locations.

If the Correctional Officer has any concerns about a prisoner returning from an escort, they must verbally notify the Responsible Officer and must complete a NOC [Notice of Concern] as soon as reasonably possible.' Ms Watkins goes on to indicate that the effect of the amended provision of SOP90 is that any prisoner, whether on remand or sentenced, who returns from court or other escorted circumstances who shows signs of distress will have a notice of concern raised.

This will then result in a risk assessment being undertaken for the prisoner in question.

6.4. I have nothing further to say in relation to the issue of occasional prisoner stress screening except to observe that a cursory examination of a prisoner for signs of distress would not necessarily reveal such underlying distress.

6.5. Hanging points This is not the first occasion on which a prisoner accommodated in F Division at the YLP has committed suicide while accommodated in a single cell. I refer in particular to the inquest in relation to the death in custody of Shane Blunden9 who hanged himself from a ventilation grille in his cell. The hanging point that Mr Ali used is different from that, but it was clearly a hanging point that was obvious and available. This Court and Courts in other coronial jurisdictions have had much to say about the elimination of hanging points in cells. The recommendations that have emanated from inquests that have involved cell hangings have been universal insofar as they have indicated that hanging points in cells should be eliminated. It is true that F Division is an accommodation unit that is set aside for prisoners who appear to be motivated to work within the industrial facilities in the prison system and who are considered to be at low risk of self-harm. However, history has shown that prisoners believed to be a low risk of self-harm occasionally fall through the cracks. Mr Ali is a case in point, as was Shane Blunden.

6.6. The affidavit of Ms Watkins indicates that the Department for Correctional Services continues to identify and eliminate hanging points from cells with a view to ensuring safe-cell designs are applied throughout prison systems. She points out that resources in this area are targeted towards those accommodation areas that hold prisoners 9 Inquest 10/2014 - Finding delivered 6 May 2015

representing the greatest risk of suicide and self-harm. She also indicates that DCS continues to alter prison cell infrastructure through funding from the annual provisions capital budget and that the work is ongoing.

6.7. The Court can only repeat what this Court and other Courts have recommended and that is that, regardless of the type of accommodation within the prison system and regardless of the risk assessment pertaining to a particular prisoner, hanging points should be eliminated from cells, especially those that provide single occupancy. I so recommend.

Key Words: Death in Custody; Prison; Hanging; Suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 8th day of May, 2020.

Deputy State Coroner Inquest Number 14/2018 (0602/2015)