Irfani v The State Coroner
[2011] WASC 270
•3 OCTOBER 2011
IRFANI -v- THE STATE CORONER [2011] WASC 270
| SUPREME COURT OF WESTERN AUSTRALIA | Citation No: | [2011] WASC 270 | |
| Case No: | CIV:3131/2009 | 14 SEPTEMBER 2011 | |
| Coram: | McKECHNIE J | 3/10/11 | |
| 15 | Judgment Part: | 1 of 1 | |
| Result: | Application dismissed | ||
| B | |||
| PDF Version |
| Parties: | ALI REZA IRFANI HAIDAR ALI IRFANI by his next friend ALI REZA IRFANI ZAHRA IRFANI by her next friend ALI REZA IRFANI ZAINAB IRFANI by her next friend ALI REZA IRFANI THE STATE CORONER |
Catchwords: | Coroner's practice Deceased in immigration detention Passage of many years Whether an inquest is appropriate |
Legislation: | Coroners Act 1996 (WA) Coroners Act 1996 (WA) (CI) (Cth) |
Case References: | Herron v Attorney-General for New South Wales (1987) 8 NSWLR 601 Re Zappelli; The Attorney General for the State of Western Australia [2000] WASC 183 Veitch v The State Coroner [2008] WASC 187 |
JURISDICTION : SUPREME COURT OF WESTERN AUSTRALIA
- IN CHAMBERS
and
In the matter of the Coroners Act 1996 (WA) (CI) (Cth)
- First Plaintiff
HAIDAR ALI IRFANI by his next friend ALI REZA IRFANI
Second Plaintiff
ZAHRA IRFANI by her next friend ALI REZA IRFANI
Third Plaintiff
ZAINAB IRFANI by her next friend ALI REZA IRFANI
Fourth Plaintiff
AND
THE STATE CORONER
Defendant
Catchwords:
Coroner's practice - Deceased in immigration detention - Passage of many years - Whether an inquest is appropriate
Legislation:
Coroners Act 1996 (WA)
Coroners Act 1996 (WA) (CI) (Cth)
Result:
Application dismissed
Category: B
Representation:
Counsel:
First Plaintiff : Dr J L Cameron
Second Plaintiff : Dr J L Cameron
Third Plaintiff : Dr J L Cameron
Fourth Plaintiff : Dr J L Cameron
Defendant : Dr C M Kemp
Solicitors:
First Plaintiff : Southern Communities Legal & Education Service
Second Plaintiff : Southern Communities Legal & Education Service
Third Plaintiff : Southern Communities Legal & Education Service
Fourth Plaintiff : Southern Communities Legal & Education Service
Defendant : Office of the State Coroner
(Page 3)
Case(s) referred to in judgment(s):
Herron v Attorney-General for New South Wales (1987) 8 NSWLR 601
Re Zappelli; The Attorney General for the State of Western Australia [2000] WASC 183
Veitch v The State Coroner [2008] WASC 187
(Page 4)
- McKECHNIE J:
What this application is about
1 Fatima Irfani was 28 years old when she died at Sir Charles Gairdner Hospital on 19 January 2003. Her family wants the Coroner to hold an inquest. He has declined and, represented by the Southern Communities Advocacy Legal and Education Service (SCALES), the family comes to this court for an order that an inquest be held. I am not satisfied that it is necessary or desirable in the interests of justice for an inquest to be held, and so the application is dismissed.
Mrs Irfani tries to come to Australia
2 Mrs Irfani, her husband and three children are of the Hazara Shia ethnic group from the Ghazni Province of Afghanistan.
3 In 2001, the family left Afghanistan after Mr Irfani had been detained and tortured by the Taliban. With the assistance of a people smuggler, the family sought refuge in Australia. Prior to arrival, however, their boat was intercepted and, on 19 October 2001, they were taken to Christmas Island where they were detained and interviewed by officials from the Department of Immigration. As they arrived without valid visas, they were unlawful non-citizens and were thereafter detained under the Migration Act 1958 (Cth).
4 When they arrived, it was noted that Mrs Irfani had a history of hypertension and was suffering from hepatitis C. The hypertension was treated by medication which assisted in reducing her blood pressure.
5 During 2002, their claim for status as refugees was rejected initially, and again on review. On 7 December 2002, they were advised that the review was unsuccessful and offered a reintegration assistance package to return to Afghanistan. On 8 January 2003, Mr Irfani signed a reintegration assistance package for the family.
Mrs Irfani's condition worsens
6 On 11 January 2003, Mrs Irfani complained of headaches on the left side of her head. Nurse Wilson who assessed her was employed by Australasian Correctional Management, the company contracted by the Department of Immigration to provide, amongst other things, health services at the Christmas Island Detention Centre.
(Page 5)
7 Mrs Irfani's blood pressure was very high at around 130/110. The headaches got progressively worse over the next two days with associated nausea, photophobia and loss of appetite. On 13 January 2003, Dr Donovan, a general practitioner, saw Mrs Irfani at Christmas Island Hospital and noted her blood pressure to be very high and increased her blood pressure medication. Further discussion about the severe headaches and elevated blood pressure between Nurse Wilson and Dr Donovan occurred on 14 January 2003. Dr Donovan prescribed the migraine drug Cafergot as a diagnostic tool to eliminate the possibility of migraine. An examination of the medical records does not reveal that Cafergot was in fact ever administered to Mrs Irfani.
8 At 11.00 am on 15 January 2003, Mrs Irfani complained of nausea and severe left-sided headache and Nurse Wilson gave her two Mersyndol tablets.
9 Shortly after noon that day Mrs Irfani collapsed. An ambulance took her to the Christmas Island Hospital around 12.30 pm. She was intubated but remained unconscious. The Royal Flying Doctor Service was contacted but advised they could not attend until the following day. A Medevac aircraft was sourced from Singapore through international SOS and removed Mrs Irfani, now gravely ill, around 2240 hours. She was flown to Perth, arriving at 0400 hours on 16 January 2009, and taken directly to Sir Charles Gairdner Hospital, arriving at 0420 hours. A head CT scan showed that Mrs Irfani had an intra-cranial haemorrhage. She was taken into theatre and a left craniotomy was performed. She was found to be brain-dead on 17 January. Her condition deteriorated and her heart stopped on 19 January 2003, and she died.
A full post-mortem examination was not held
10 Mr Irfani objected to a full post-mortem examination on religious and cultural grounds. The Deputy State Coroner accepted the objection and only an external examination was conducted. Dr Cadden, a forensic pathologist, determined the cause of death to be intracranial haemorrhage based on his review of the medical history of the deceased.
The fate of the family
11 Mrs Irfani's family had been flown to Perth to be with her. They were returned to Christmas Island and on 15 February 2003 were removed from Australia with the body, arriving in Kabul, Afghanistan on 19 February 2003. The situation was still dangerous and they soon left for Pakistan and now live in Quetta.
(Page 6)
A very great delay
12 The mere recitation of the date of death and the date of this judgment indicates there has been a huge delay in resolving the issue. Ms Mary Anne Kenny of SCALES has set out exhaustively the various procedural and other steps that have been taken in the intervening years and it is unnecessary for me to reproduce her chronology and reasons which I accept. The delay does not seem to have been caused in any way by the family. Shortly after the death, the Australian Human Rights Commission (then known as the Human Rights and Equal Opportunity Commission) wrote to the Coroner stating that the circumstances of a death in detention raised important issues relating to the duty of care of individuals who are denied their liberty and encouraged the Coroner to hold an inquest into the case. It appears that a solicitor was also engaged by Mr Irfani at around that time. There was a hiatus between then and the beginning of 2007 when the family's present solicitors, SCALES, were engaged.
13 Following SCALES involvement, the Coroner engaged an independent medical practitioner, Dr Turnbull, to review the medical treatment afforded to Mrs Irfani, while SCALES engaged Dr David Blacker, consultant neurologist and stroke physician, to review the papers. While Dr Blacker found the treatment to be generally appropriate, he considered the prescription of Cafergot was a serious error.
Dr Turnbull's assessment
1. In my opinion, the length of time taken to diagnose Mrs Irfani's condition was acceptable. Her hypertension was never severe and it was managed appropriately.
2. I cannot say why RFDS were unable to attend before the following day but I think the time it took SOS International to arrive at Christmas Island from Singapore was reasonable. All this time she was being managed at CIDH by three doctors and nurses under the guidance of specialists from SCGH.
3. In my opinion, the standard of care offered by Dr Donovan was reasonable and acceptable.
4. There was a plan to manage Mrs Irfani's hypertension and in my opinion she was adequately managed in that regard. She was given an antihypertensive and Dr Donovan requested that her BP levels be measured and noted that further medication might need to be added if things did not improve.
5. It was totally reasonable that she remain at Christmas Island for the management of her hypertension. It was not that severe that it
- warranted referral to Australia. This question seems to imply a perception that she had a cerebral bleed because her blood pressure was so high it caused a rupture of an artery in her brain. It is not that simple. It is highly likely that she bled from an aneurysm in a cerebral artery and the blood pressure does not have to be that high for an aneurysm to bleed. In addition, the small bleeds from aneurysms usually cause a sudden 'thunder clap' headache often with associated neck stiffness as the blood irritates the meninges. There is no suggestion of that history in this case.
- 6. This case demonstrates to me that they coped very well with this catastrophic emergency.
Dr Blacker's assessment
A) Comments on early management.
…
This initial management was, in my opinion, entirely appropriate. It would appear to me, that on 13/1/03, the patient did NOT have signs of hypertensive encephalopathy or malignant hypertension, either of which would have required more intensive, and usually hospital based treatment.
…
If indeed Cafergot was prescribed and administered, in my opinion this would be a serious medical error; since this vasoactive, anti-migraine agent is contraindicated in severe, or inadequately controlled hypertension. Additionally, I dispute the diagnosis of cluster headache or migraine in these clinical circumstances, where the headache is most likely related to the hypertension. This is based on the absence of any prior documented history of migraine, and the duration of the symptoms.
Whether or not Cafergot was administered is a key issue, since this would lead my assessment to conclude that this early phase of management was INAPPROPRIATE … Otherwise, my opinion is that the management was reasonable, through to the time of Mrs Irfani's collapse.
B) Comments on treatment after her collapse on 15 January 2003.
It would appear to me that the emergency management on 15/1/03 was reasonable, and in fact commendable …
…
C) Opinion on delays, and difference in management should she have been in the Metropolitan area.
(Page 8)
- I understand that there are concerns regarding the delay in transportation to SCGH, and specifically there is a question as to whether or not the outcome would have been different if more rapid evacuation had occurred.
I note that she was observed to have had unreactive pupil reflexes as early as 1210 on 15/1/03. The St John's Ambulance 'Patient Care Record' (completed 6 days after the incident), notes that the 'nurse advised GCS of 3'. This neurological score, along with the absent pupil reflexes would suggest a dire prognosis from an ICH) right from the outset. Even if this patient had been in the metropolitan area, given the severity of the ICH, and the poor prognostic clinical signs very early on, I very much doubt the outcome would have been any different. (emphasis in original)
Was Cafergot administered?
14 Counsel for the Coroner conducted a comprehensive review of the matter, noting the following evidence which would support a finding that Cafergot was not administered:
• The prescription by Dr Donovan on 14 January 2003 is recorded on the deceased's medication chart as 'PRN' meaning as needed. There was no direction to administer it.
• Dr Turnbull has provided information on cafergot (attached to his second report). It is given at the first sign of headache symptoms in order to stop the onset of the headache. I note that Dr Donovan prescribed it as a 'diagnostic tool' with regard to the suspicion of migraine/cluster headaches. Nurse Wilson only attended the deceased when the headache had already manifested, thus providing no opportunity to administer the cafergot as a diagnostic tool.
• Other medications prescribed by Dr Donovan on the medication chart including the myrsendol prescribed by Dr Donovan for pain relief, are annotated as having been administered so it is clear the chart was in use and if cafergot was administered there is no reason it wouldn't be recorded by Nurse Wilson as the other medications were.
• Nurse Wilson has provided a statement and she makes no mention of administering cafergot to the deceased, but does account for the administration of other drugs prescribed by Dr Donovan over the relevant time period (13 - 15 January 2003).
The Coroner's position in relation to an inquest
15 In a letter of 26 October 2007, the Coroner wrote to SCALES:
As you may be aware, my attitude in respect of this matter was initially that it would be appropriate for a public inquest to be held and, for
(Page 9)
- example, on 17 February 2003 I wrote to the Officer in Charge of Christmas Island Federal Police advising that the WA Coroner's Court had assumed jurisdiction and that it was proposed that an inquest would be held.
16 He detailed communications with the previous solicitors, noting that there had never been a response, before advising that in the context of the unfortunate four year delay he would arrange for an independent medical practitioner to review the medical file. Dr Turnbull was engaged.
17 On 7 December 2009, the Coroner wrote to SCALES:
Had this matter been pursued vigorously at an earlier stage, I would have considered it an appropriate matter for a public inquest as the circumstances of the detention were analogous to the situation of a person held in care for the purposes of the Coroners Act 1996.
In the context of the unfortunate delays, however, I have referred this matter to counsel assisting who has compiled a comprehensive overview and discussed issues relating to whether or not it is desirable to hold an inquest. For the reasons outlined by counsel assisting, I do not consider it is now appropriate to hold a public inquest into the circumstances of this death and I propose to complete the matter by way of finding based on the papers.
18 That finding has been delayed pending this application.
The history of this application
19 Application to this court was made on 18 December 2009 within the seven days of the Coroner's refusal: Coroners Act 1996 (WA), s 24(2). The State Coroner filed an appearance on 25 February 2010. The Coroner has advised that he does not intend to make submissions on the merits of the application, and only seeks to be heard on the proper construction of the Coroners Act and any procedural matters that may arise. On 5 March 2010, Simmonds J made orders adjourning the matter to a special appointment. On 6 August 2010, the matter first came before me. After discussion as to whether there was a matter arising under The Constitution, I directed the service of notices under the Judiciary Act 1903 (Cth), s 78B, and granted liberty to apply on short notice. Subsequently, the plaintiffs' originating motion was amended by Master Sanderson on 21 October 2010. The amendment was brought about because on further consideration counsel identified the Coroners Act 1996 (WA) (CI) (Cth). This Act confers power on the State Coroner to investigate a death in an immigration detention centre on the Territory of Christmas Island.
(Page 10)
- SCALES wrote to the Coroner on 27 August 2010 asking that he exercise his jurisdiction under the Commonwealth Act.
20 In his letter of refusal dated 8 September 2010, the Coroner said:
This is to advise that my views in respect to holding a public inquest are unchanged from those expressed in my letter of 7 December 2009 addressed to you when a similar application was made pursuant to the Coroners Act 1996 (WA). In particular, having reviewed the comprehensive overview conducted by counsel assisting in this matter and referred to in my letter of 7 December 2009, I do not consider that it is now appropriate to hold a public inquest into the circumstances of the death. As you, no doubt, are aware little can be gained from the holding of a public inquest unless real issues have been identified in respect of which available witnesses can give evidence which would go beyond the contents of any statements or reports which have already been obtained or which can be obtained. The Coroner's Court has limited resources and witnesses are never called to give oral evidence unless there is a perceived real benefit to be achieved by their doing so.
21 I had little doubt that the Coroner would require a Federal grant of power to exercise power to investigate the circumstances of Mrs Irfani's detention, the issues of the Commonwealth's duties to her and the appropriateness of the treatment. However, as that grant has been identified under the Coroners Act 1996 (WA) (CI) (Cth), the action is not now a matter arising under the Constitution or involving its interpretation and notices under s 78B are unnecessary.
Does this case fall between the two Acts?
22 A question arises whether the Coroner is in fact exercising Federal or State jurisdiction. The death occurred in Western Australia, not on Christmas Island. However, the Irfani family do not want an investigation as to the treatment of Mrs Irfani at Sir Charles Gairdner Hospital, but of the circumstances arising as to her treatment while in detention on Christmas Island. In view of the conclusion I have reached as to the application, I will not answer this jurisdictional question but proceed on the assumption that the Coroner would be invested with sufficient jurisdiction to examine the latter question if necessary.
23 The amended originating motion was filed on 8 March 2011. On that date, SCALES requested that the matter be relisted before me. For reasons probably related to my active court schedule, a convenient date for all parties could not be found until September 2011.
(Page 11)
24 This history explains the delay but it remains the fact that the events are nearly nine years in the past.
The Coroners Act 1996 (WA) (CI) (Cth)
25 The Christmas Island Act 1958 (Cth) s 8A provides, subject to exceptions, that the provisions of the law of Western Australia as in force in Western Australia from time to time are in force in Christmas Island, a Territory of the Commonwealth. Under s 14B, the Coroner's Court has jurisdiction as if Christmas Island was part of Western Australia and the practice and procedure applicable is the same as that in Western Australia. The Act is identical to the State Act, except references to the State have been replaced by references to 'the Territory'. Therefore, a reportable death is defined as meaning a Territory death:
(a) that appears to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from injury; or
...
(e) of a person who immediately before death was a person held in care.
The Coroners Act 1996 (WA) defines 'reportable death'
26 It is a common ground that Ms Irfani was not a person 'held in care' as defined in the Coroner's Act.
27 If she was an inquest must be held. Dr Cameron's submission is that as she was in detention, her situation is indistinguishable from a person held in care and an inquest should be held.
28 The Coroner has jurisdiction to investigate a death if it appears that the death is or may be a reportable death (s 19(1)). Mrs Irfani's death may be a reportable death. Clearly, the Coroner considered he has jurisdiction to investigate the death and this is not in issue.
29 A Coroner investigating a death must find, if possible, the identity of the deceased, how death occurred, the cause of death and may comment on any matter connected with the death, including public health or safety or the administration of justice: Coroners Act s 25. An investigation includes an inquest and an inquest is a formal hearing. A Coroner who has jurisdiction to investigate a death may hold an inquest if the Coroner believes it is desirable: s 22(2). Inquests into deaths are dealt with under the Coroners Act pt 5. A Coroner is not bound by the rules of evidence and may be informed or may conduct an inquest in any manner the
(Page 12)
- Coroner reasonably thinks fit: s 41. The Coroner may summon witnesses, order witnesses to answer questions on oath, and be assisted by counsel and must record evidence.
This court's power to make an order for an inquest
30 The Supreme Court may order that an inquest be held if it is satisfied that it is necessary or desirable in the interests of justice: Coroners Act s 24(3). This involves a discretionary value judgment: Veitch v The State Coroner [2008] WASC 187 [35].
31 In Herron v Attorney-General for New South Wales (1987) 8 NSWLR 601, Kirby P described those words 'in the interests of justice' as plainly words of the widest possible reference; indeed, there could be scarcely a wider judicial remit.
32 The submissions of counsel for the plaintiffs focus on a number of matters. Acknowledging that Mrs Irfani did not fall within the provisions of a 'person held in care', counsel pointed to Coroners Acts in Queensland, New South Wales, Victoria, South Australia, Northern Territory and the ACT which do include persons in detention. The plaintiffs submit that the words of s 24 confer a very broad discretion on the court. They also submit that it is necessary in the interests of justice that every death in immigration detention be treated as if it were the death of a person held in care.
33 It is submitted that sufficient concern has been expressed as to the medical treatment of immigration detainees for it to be in the interests of justice that an inquest be held where a detainee dies in immigration detention or shortly after release from immigration detention. The plaintiffs support this argument by reference to two documents; a with the report from the Australian Human Rights Commission '2009 Immigration detention and offshore processing on Christmas Island'; and 'Preliminary observations and recommendations of the United Nations Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health', dated 4 December 2009 at Canberra. In 2009, the Human Rights Commission reported at page 49:
• There are no medical specialists (such as optometrists, physiotherapists, radiologists or others) located on Christmas Island.
• Pregnant detainees do not have access to childbirth facilities on the island.
(Page 13)
- • Some detainees at the Christmas Island IDC raised concerns about the length of time they had to wait to see a nurse or doctor.
• Because of the remote location, IHMS staff work on short rotations of two to six weeks at a time. Some concerns were raised with the Commission that this constant rotation, if not accompanied by thorough handovers in between, may lead to patient needs 'falling through the cracks'.
• If there was an emergency medical situation in one of the detention facilities on the island, it could take an hour or two for an ambulance to arrive. This is a particular concern at the Christmas Island IDC, given its isolated location. The island does not have a paid ambulance service - the ambulance is staffed by local volunteers. DIAC informed the Commission that it intends to implement a three month pilot program under which a paramedic will be stationed at the IDC overnight.
• Detainees on the island have very limited access to dental care. Detainees face long waiting lists as there is only one dentist on the island to meet the needs of both the local community and detainees. Two sessions each week are set aside for detainees - one for adults and one for children. DIAC has informed the Commission that it is attempting to arrange for a mobile dental unit to be transported to the island.
34 The Rapporteur, Mr Anand Grover, did not visit Christmas Island and speculated as to health services and other services being extremely challenging.
35 The plaintiffs' position as forcefully expressed by counsel is that when a death takes place in immigration detention it is essential in the public interest that there is an inquest. The death is analogous to, and indeed for all intents and purposes is, a death in custody.
36 When there is an offshore processing system and the Commonwealth's business model is to detain persons offshore and warehouse them until review, it is even more important that there be a formal inquiry.
37 I partially accept the submission. Indeed, the Coroner would have held an inquest as he indicated at an early stage. However, this issue is not in such absolute terms as the plaintiffs put it. The ultimate purpose of the Coroner is to inquire into a particular death. On the facts, I am unable to accept that the circumstances of Mrs Irfani's death, being well documented, would lead to the wider inquiry sought by the plaintiffs.
(Page 14)
The effect of the passage of time
38 This application is not an appeal from the decision of the Coroner refusing an inquest. It is a matter involving a discretionary judgment as to where the interests of justice might lie. I am not bound by the Coroner's decision. Nor do I have to find error in that decision.
39 It is relevant to note that in 2003 the Coroner considered the matter was appropriate for a public inquest. The factors then existing would have rendered it appropriate for an inquest to be held in the interests of justice.
40 However, by 2009, things had changed. The first is the passage of time. Of course, the passage of time by itself is not an insuperable obstacle to holding an inquest: Re Zappelli; The Attorney General for the State of Western Australia [2000] WASC 183 is one example. There may be many circumstances in which an inquest is appropriate notwithstanding that a long period of time has elapsed between the death and the inquest. However, it is one of the relevant factors to be taken into account.
41 In the inquest into the death of Mohammed Yousef Saleh, the Coroner noted that the deceased was not a person held in care, but that the Coroner may comment on any matter connected with the death, including public health or safety or the administration of justice. He continued:
It was submitted that as Section 3 of the Coroner's Act 1996 does not include persons held in Commonwealth immigration detention facilities in the definition of 'persons held in care' that there should be an amendment to the definition section of the Act to that affect. It was contended that such an amendment would '… necessary for the administration of justice'.
In this case the death occurred in circumstances in which it was a 'reportable death' and, therefore, was the subject of a coronial investigation. In my view the circumstances surrounding the death are not such that it is apparent that it would be 'necessary for the administration of justice' that there should be legislative change. Importantly, also, whether or not such a change should occur involves policy considerations which are the province of government, not of the judiciary.
42 I agree with these remarks, notwithstanding the plaintiffs' submissions that if an amendment to the Coroner's Act was made, the Coroner would be required to comment on the quality of supervision, treatment and care of the deceased while in that care even if those factors were not connected with the death.
(Page 15)
43 There are three responses to this submission. First, the Coroner is plainly correct in identifying these matters as policy considerations for Parliament. A recommendation by the Coroner for legislative amendment is of limited utility. Secondly, the Coroner, rightly or wrongly, has expressed his considered view in the case of Saleh. A change of mind is not entirely out of the question but would have to be regarded as hopeful.
44 Thirdly, and more importantly, the focus of an inquest is into the death and the immediate circumstances giving rise to the death. It is not a general inquisition into the detention system. In Mrs Irfani's case, both Drs Turnbull and Blacker independently concluded that the standard of medical response on Christmas Island was, subject to one exception, a reasonable response. That exception is the question of Cafergot. However, there is no evidence that Cafergot was in fact administered and had anything to do with the death. Counsel for the plaintiffs has also raised the question of interpreters at medical appointments. It is not known if an interpreter was present at either the consultations with the doctor or with the nurse. However, the actions taken by them indicate that Mrs Irfani was able to make her symptoms known sufficiently.
45 There was some delay in transfer to Perth. In a State as large as Western Australia, it is inevitable that persons who live remotely will, unfortunately, experience delays in being transferred to a primary medical centre. The same applies to persons on Christmas Island, whether in detention or otherwise.
46 I am not satisfied that there is any utility or public interest in now holding an inquest into the circumstances of Mrs Irfani's death. The circumstances of her death after such a long passage of time are now not an appropriate vehicle to explore those matters regarding her treatment in detention which existed in 2002 and 2003 because there is no nexus between any such treatment and her unfortunate demise. Amendment of the Coroners Act to include immigration detention in the definition of a person held in care is not a sufficient reason for an inquest, it being principally a matter of policy for government and legislation by Parliament.
47 The Coroner has undertaken an investigation and will make findings. I am unpersuaded that a formal inquest as part of the investigation will sufficiently advance the Coroner's knowledge in this case in the interests of justice.
48 For these reasons, I dismiss the application.
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