Abstract
Institutional confinement is paradoxically characterised by intense surveillance, while those confined are often rendered invisible as persons of value and agency. Our capacity to ‘see’ violence in such sites can also be harder to discern when it is the manifestation of neglect: not so much as mistreatment but
Introduction
Hamid Khazaei was a 24-year-old man from Iran who arrived by boat in 2013 on the Australian territory of Christmas Island, seeking refugee protection. He was subsequently transferred to a detention centre located offshore on Manus Island in Papua New Guinea (PNG) as an effect of Australia's punitive border protection laws (Giannacopoulos and Loughnan, 2020). In 2014, within a few days of presenting at the medical clinic at Manus Island and complaining of being unwell, Hamid was declared brain dead (Coroner’s Court of Queensland, 2018). Some years later, thousands of kilometres from Manus Island, Mrs Annunziata Santoro – or Nancy as she was known – a resident of Assisi Aged Care, a Residential Aged Care Facility (RACF) in Melbourne, developed a pressure wound in her foot; the wound festered, developing into a bone infection. By the time it was diagnosed, the only options remaining were amputation or palliative care. Nancy was transferred to a palliative care site where she died two days after transfer (Tracy and Briggs, 2019a). Both deaths were the result of neglect.
These stories signal a startling coalescence in patterns of abuse in immigration detention and aged care 1 , despite clear distinctions between them and regardless of whether sites are purposed for ‘care’ or punishment (Australian Human Rights Commission, 2020; Briskman and Goddard, 2008: 221; Dehm et al., 2021; Human Rights Watch, 2020: 6–7; Maker and McSherry, 2018; Nethery, 2021; Sidoti, 1998: 126; Westbury et al., 2019). Evidence of abuse in aged care reveals it as a site of coercive confinement (Dehm et al., 2021: 63, 99; Repo, 2019) and systemic neglect (Greener, 2020) mirroring practices of control and mistreatment in immigration detention. 2 Accordingly, the focus in this article is upon the potential for places of confinement – including those purposed for ‘care’ – to foster practices which too easily result in violence, through neglect.
I do not pretend that the lives of Hamid Khazaei and Nancy Santoro, or the settings in which they died, are comparable in all respects. However, in examining their preventable deaths, I aim to elicit an appreciation of the parallels in these distinct sites. Both deaths resulted from the diminished recognition of Hamid and Nancy as human subjects, through what I describe as a ‘necrositic’ relationship to death: death produced by the site in which a person resides. Both were effectively ‘subjected to conditions of life conferring upon them the status of living dead’ (Mbembe, 2003: 80). The cause of their deaths, resulting from the failure to treat skin wounds, obscures the outright violence of these sites: instead, we are called to witness the often imperceptible yet unremitting movement towards death through the failure to see the site of the wound, to record and to treat it. This failure to really
Two key documents were the subject of analysis: the report of the Coronial Inquest into the death of Hamid Khazaei, and relevant transcripts from hearings conducted by the Royal Commission of Inquiry into Aged Care Quality and Safety, relating to the life and death of Nancy Santoro. The Coronial Inquest would have been unlikely had Hamid died in offshore detention. Since he died while in custody after transfer to Australia, laws enacted after Australia’s Royal Commission into Aboriginal Deaths in Custody required formal investigation of his death. 3 The Royal Commission on Aged Care Quality and Safety was established in response to media reports of systemic abuse in aged care (Connolly and Ferguson, 2018). Nancy’s death might not have been investigated in such detail had the Commission not been established. These public documents provide insights into institutional practices and forms of conduct that are often hidden from view (Noaks and Wincup, 2004: 107–108) until the emergence of a crisis moment, especially in closed environments, given that ‘abuse thrives in darkness’ (Sadler, 2021). A close reading of these documents enabled an intensive, narrow focus upon practices of neglect in sites of confinement. My approach was archaeological (Parker, 2007: 238) seeking to uncover the detailed trail of events leading to their deaths, and how many small actions or (in)actions can lead to human suffering and death, despite not appearing as explicit acts of violence. The reports were not easy to read. I was often left gasping at the ongoing litany of errors and inaction that piled up, page after page. As Sara Dehm (2021: 341) has remarked for example, the Coronial report detailing Hamid’s death makes for ‘harrowing reading’. Paradoxically, the official documentation of neglect and administrative missteps in the ‘care’ of Nancy and Hamid at times amplified the horror of their deaths, in part an effect of the bureaucratic, restrained yet impactful language of the documents (Parker, 2007).
This article responds to calls by criminologists and carceral geographers for a deepened appreciation of the diverse forms that confinement takes, beyond those associated with the prison, to hospices, nursing and care ‘homes’ (Disney and Schliehe, 2019; Greener, 2020; Moran, 2015: Moran et al., 2018; Moran and Schliehe, 2017; O’Donnell and O’Sullivan, 2020; Repo, 2019; Watts, 2010). Rather than examining explicit forms of coercive control in some of these sites, such as the use of isolation and restraints, I explore the violence that emanates from neglect. Although there has been extensive attention to neglect in refugee camps and detention centres (Briskman et al., 2012; Davies et al., 2017; Grewcock, 2017: Mayblin et al., 2020; Perera and Pugliese, 2018; Pugliese, 2009; 2008; Tazreiter, 2020), the research on aged care has tended to focus on sexual abuse and restrictive practices (Bows, 2019; Maker and McSherry, 2018; Peisah et al., 2020). Yet recent interventions (Greener, 2020; Repo, 2019; Robertson and Travaglia, 2019) argue for a heightened appreciation of the dynamics of violence inhering in residential aged care sites, despite the image of those residing there as the (passive) subjects of care. This is significant as the very terminology of ‘care’ in the naming of institutions tends to limit our appreciation of how coercive control and neglect emerge in these settings. There remains however, a persistent risk that care can transform into paternalistic forms of control, manifesting in oppression and abuse (Philo and Carr, 2019: 241–242). In her study of a Finnish nursing home, Virve Repo (2019: 235, 237) describes how the tendencies for ‘“careless” control’ too easily transmute into ‘quasi-carceral experiences.’ This is fostered by austerity measures as well as by differential power relationships between staff and typically vulnerable residents in aged care facilities (Greener, 2020).
Emerging research is thus increasingly attuned to the evident disregard for human life in sites commonly associated with ‘care’ (Dehm et al., 2021; Disney, 2017; Greener, 2020: Repo, 2019). Extending on this, I aim to reveal the implicit violence of those practices which are less marked by outright physical and psychological mistreatment and conduct, than by the failure to treat, and to
Abandonment, exception, death
Agamben famously proposed that sovereign power under biopolitical conditions is exercised through the spatial division of populations, in which those deemed ‘bare life’ are relegated to zones of exception and situated beyond the protections of law (Agamben, 2005: 2). Among the defining characteristics of zones of exception for Agamben is ‘that growing sections of humankind are no longer representable inside the nation-state’ (2000: 22). The exception, for Agamben, is not just a ‘temporal suspension of the state of law’ but ‘acquires a permanent spatial arrangement that remains continually outside the normal state of law’ (Mbembe, 2003: 12–13). In such circumstances, the boundaries between inclusion and exclusion are increasingly blurred (Agamben, 1998: 37) between those whose lives have ‘relevance’ and those whose lives do not (Pratt, 2005: 1055). Deaths resulting from neglect in aged care and immigration detention are, I argue, illustrative of Agamben’s claims that the camp is the ‘nomos’ of modernity. Whether or not they are situated within law and regulated by it, both sites mark the division between those deemed worthy of life and those who live at the margins. Nancy and Hamid lived and died within
Although there is widespread acknowledgement (Dauvergne, 2000; Larking, 2016; Orford, 2005) that refugees in detention camps are effectively situated outside the reach of human rights, those in aged care facilities have conventionally attracted less attention, relatively speaking, as subjects bereft of rights and therefore potentially ‘doomed to death’ (Agamben, 2000: 33). Paradoxically Nancy’s death Bare life is no longer confined to a particular place of definite category. It now dwells in the biological body of every living being (Agamben, 1998: 140).
Agamben thus pushes us to reflect on how exceptional spaces are produced and sustained
For Mbembe, power must be understood as more than simply the power over the management of life, arguing that Foucault’s concept of biopower (Foucault, 1978) is ‘insufficient to account for contemporary forms of subjugation of life to the power of death’ (Mbembe, 2003: 39). Rather, power is exercised through death, over particular – and typically racialised – populations, marking a ‘capacity to define who matters and who does not, who is disposable and who is not’ (Mbembe, 2003: 27). To exercise sovereignty is then, ‘to exercise control over mortality …’ (Mbembe 2003: 11), to determine who must die (Mbembe, 2003: 27). This directs our attention to the production of ‘death-worlds, new and unique forms of social existence in which vast populations are subjected to conditions of life conferring upon them the status of living dead’ (Mbembe, 2003: 40). And it pivots our focus towards practices targeted not at the management of life (Foucault 1978) but at its destruction.
While some are ‘ushered into the worlds of life and vitality… others are funnelled into places of ‘slow living death and dead living’ (Lamble, 2013: 242). This is the Janus face of biopolitics: biopolitics and necropolitics hold together in ways that allow some to live, while making others die, or ensuring that they are ‘kept alive but in a state of injury’ (Mbembe 2003: 21) even to the moment of death. This state of injury itself functions as a means of control (Davies et al., 2017: 1268). The gradual yet permanent wounding experienced in places like aged care and immigration detention centres and refugee camps (Davies et al., 2017: 1279; Dehm, 2021; Mayblin et al., 2020: 110) contrasts with the ‘outright extermination’ marking other forms of necropower (Mayblin et al., 2020: 110).
6
Yet even though these injuries are imposed indirectly, they are felt concretely, in and on the body (Davies et al., 2017: 1280; Johansen, 2013). The deaths of Hamid and Nancy are illustrative of how necropower is exercised not simply through direct force, but through the violent effects of state
The deaths of Hamid and Nancy were also intimately connected to a prior social death and to specific conditions of confinement which limit ‘the possibilities for resistance and survival’ (Lamble, 2013: 245). Power over who must die thus extends beyond physical death towards social death, to those ‘social relations’ produced through ‘prolonged exposure to violence, neglect, deprivation and suffering’ (Lamble, 2013: 242). For our elders, social death manifests through the loss of social connection; among refugees it is experienced through displacement and social exclusion (Králová, 2015: 236) and prolonged detention (Bhatia, 2020: 278). In losing social meaning, neither our elders nor refugees ‘count as lives that matter’ (Jonsson, 2015: 285–284). Aged care resident Merle Mitchell describes this loss: There’s a shock when you move into aged care. There is the shock of loss because what happens is it is so quick. There’s not the recognition of loss because loss is not just death. Loss is loss of your way of life…There’s the feeling of suddenly I’m in an institution. I have to follow what the institution wants, the time to get up, the time to have meals and there’s no–there’s no choice (Tracy and Briggs, 2019b: 103).
In what follows, I intentionally dwell at length on the incremental progression of neglect, to bring to light the move towards death as the culmination of many small
It is worth reflecting here on the observations of Behrouz Boochani, a Kurdish Iranian writer detained in Manus at the time that Hamid died. Describing Hamid, he gestures towards the presentiment of a similar fate for all the men at Manus Island detention centre: On a few occasions I see him on the way to the clinic. I have heard that the mosquitoes have bitten him. He is in a terrible state. This phrase is common in the prison. The prisoners say 'He's in a terrible state'. A dreadful feeling comes over them. … The clinic is a few containers set up at the end of the prison, stuck up against Oscar. The site is filthy and the clinic makes a ridiculous attempt to look like a hospital. Warehoused in that site are tiny glass bottles of medicine and big glass bottles of medicine …. But it is rare that any medicine other than paracetamol is prescribed. The clinic runs by a series of macro and micro rules and regulations, which serve as obstructions and diversions. When a persons’ report is submitted to the clinic, any bizarre thing could happen to them and anything at all is possible (Boochani, 2018: 302–303).
The possibility, and indeed the ‘sanctioning’ of harms (Bhatia, 2020: 280) and of death are associated with the sites of the detention centre and with residential aged care (Power, 2020). As the report of the Royal Commission later found, RACFs are often marked by the ‘inadequate prevention and management of wounds’, delivering the potential for septicaemia and death (Tracy and Briggs, 2019b: 6).
The ‘smiling youth’ who loved flowers: Hamid Khazaei and ‘a lot of little disasters’
Hamid Khazaei, born in Iran, was regarded as a kind, respectful young man who loved soccer and flowers (Boochani, 2018: 296–298). He sought protection as a refugee, taking a boat arranged by people smugglers, with the aim of arriving on Australian territory to seek protection there. However, successive Australian governments have effectively externalised Australia’s responsibility for refugee protection onto other nation states, through laws preventing anyone who arrived on Australian territory by boat, without prior authorisation, from ever being settled there (Parliament of Australia, 2016). This policy led to the detention of over 1500 asylum seeker men for six years on Manus Island, over 800 km north of the capital of PNG, Port Moresby, and the detention of asylum seeker families, women and children in the Pacific Island nation-state of Nauru. Australia’s border protection regime has been routinely criticised as inhumane, breaching Australia’s responsibilities under the Refugee Convention (Australian Human Rights Commission, 2013; Dastyari and Hirsch, 2019; Grewcock, 2018; Nethery and Holman, 2016; Ozdowski, 2004; Sidoti, 1998; Taylor, 2013; Triggs 2014). In July 2021, there were 108 people still detained in offshore processing centres in Nauru and 125 in PNG (Refugee Council of Australia, 2021).
Four years after Hamid died, the Coroner found that Hamid’s lower leg first became infected from a mosquito bite while he was detained in the Manus prison (Coroners Court of Queensland, 2018: 1). Left untreated, this small wound from an insect bite culminated in a series of cardiac arrests, and ultimately, multiple organ failure. Hamid first presented at the local clinic at Lombrum, a small town on Manus Island, at 5.30pm on 23 August 2014, having been unwell for two days, with a fever, chills, aches and a sore throat. Initially, there was scant attention to the surface of his skin, and the possibility of infection. A small, infected sore was later noticed on his lower leg and another in his groin. He was put on intravenous antibiotics and pain relief medication. His fever did not abate. It was noted that he had lesions and abscesses on his skin, but there was minimal follow-up. Medical staff mainly focused on measurements indicated by medical equipment, and their own assessment of whether or not he ‘looked ok’. Despite continued antibiotic treatment, Hamid’s fever remained high. His blood pressure dropped and heart-rate increased. By late on 24 August, he was vomiting and in a wheelchair. Clinical staff determined that urgent medical evacuation was needed. Yet what followed were significant delays, missteps and a failure to act with due regard for his condition by the Department responsible for his care (Coroners Court of Queensland, 2018: 13–19).
The Coroner’s report stated that by the morning of 25 August 2014, Hamid’s condition had worsened considerably. Senior medical officer, Marten Muis, and emergency doctor, Leslie King, agreed that urgent evacuation should occur, on a scheduled commercial flight from Manus Island to Brisbane, Australia, at 5.30pm that afternoon. The International Health and Medical Services – contracted to provide health services for those detained in offshore detention facilities – suggested Port Moresby Hospital instead, despite the limited medical support there for serious conditions (Coroners Court of Queensland, 2018: 28). It was later found that this decision clearly contributed to Hamid’s worsening condition (Doherty, 2014, 2017). Attempts to discuss Hamid’s transfer with Departmental Assistant Director of Detention Health Services, Caroline Gow, in Australia’s capital, Canberra, were marked by poor communication between staff in Canberra and clinical and other staff at Manus. Gow seemed confused about the proposed time for transfer, and the notification and approval processes process for Hamid’s urgent evacuation, later indicating that she thought the flight was departing at 11am the following day, 26 August. Just after 1pm on 25 August, departmental staff at Manus sent an email to Amanda Little, Canberra-based director of detention health services, requesting the ‘urgent medical transfer’ of Hamid to hospital. Medical staff on Manus stated that ‘this client has “exhausted all antibiotic treatment” options at Manus …. [with a] risk that the infection will lead to “sepsis” as a “life-threatening, widespread systemic infection”’ (Coroners Court of Queensland, 2018: 34, 26).
Little was in meetings all afternoon and did not see the transfer request. Gow called to alert her to the email. Finally, by 6pm, Little responded but failed to escalate the request for approval, saying: I am wondering why this can’t be managed at Lorengau hospital? Even using something ‘unusual’ should be able to be managed locally. Is there a [drug] supply issue that we are unaware of? Again, these should be brought in, rather than the person being transferred if this is the case. DIBP [Department of Immigration and Border Protection] staff on island are being pushed for this urgent transfer in the next 18 hours, however I don’t have adequate information to be able to escalate at this point if this is still warranted (Coroners Court of Queensland, 2018: 33–34).
Shortly afterwards, Renshaw called again to emphasise the critical nature of Hamid’s condition. An hour later, Little emailed Assistant Secretary, Paul Windsor, in Canberra to request that transfer be escalated. But Windsor had gone home for the day, not reading the email until 13 hours later. By this time, Hamid’s condition was critical with doctors commenting, ‘There’s no doubt he’s now an emergency, he’s deteriorated very rapidly in the last few hours. We need to get this guy out fast’ (Coroners Court of Queensland, 2018, Exhibit). Finally, at 8.30am, 26 August, Windsor read the transfer request email from Little and escalated the request to the First Assistant Secretary of the Department, John Cahill. Ten minutes later, Hamid’s transfer was approved by the Department. In the meantime, Hamid’s condition had deteriorated such that he could not fly on a commercial plane and other arrangements were necessary. The request to transfer him to Brisbane – the closest site for adequate medical care in Australia – rather than Port Moresby, was denied: the Departmental order to take him by air ambulance to Port Moresby’s Pacific international hospital, was made in defiance of doctors’ recommendations for transfer to Brisbane (Coroners Court of Queensland, 2018). Reflecting on this bureaucratic resistance to delivery of urgent care, one of the doctors stated, ‘I have never once seen this sort of bureaucratic sanctioning required anywhere’ (cited in Grewcock, 2017: 83).
By late morning, Hamid was septic, moaning in pain and distressed. After being driven to the airfield from the detention centre, a drive of over 30 minutes on a rough road in Manus, he was left lying on a gurney in the hot sun at the tarmac, waiting for transfer to Port Moresby. On arrival at Port Moresby International Hospital, Hamid was put into a cubicle and intubated, with directions that he be checked 2-hourly. Staff claimed that he was still conscious at this stage and responsive with a central pulse, albeit weak. However, he had lowered oxygen levels and was breathing fast. His skin was a very dark blue colour, he was sweaty, and his skin was cool to touch. A treating doctor remarked that Hamid was ‘the most awful colour that I’d ever seen a human being… I’ve never seen anybody deteriorate that fast … he looked awful’ (Coroners Court of Queensland, 2018: 42).
The ventilator appeared ineffectual: it was discovered some hours later that there were holes in the ventilator tube and it was designed to fit children, not an adult male. In an extraordinary intervention 5 hours after Hamid was admitted, an International SOS specialist emergency medical team – located in Port Moresby to treat Australian federal police officers, but not asylum seekers – was called to the hospital. The doctor in this team later recounted that: When I went into the room, I saw the patient in a bed on left-hand side. I immediately noticed alarms going off, both the ventilator was alarming and the monitor with patient’s vital signs was alarming. There was a nurse stood on the other side of the bed, not attending the patient … (Coroners Court of Queensland, 2018: 62)
By this time, both treating doctors at Port Moresby considered Hamid to be ‘neurologically dead’ (Coroners Court of Queensland, 2018: 65). He suffered up to three cardiac arrests overnight on 26 August, as a direct effect of septicaemia, before attempts were made to resuscitate him (Coroners Court of Queensland, 2018: 64). By the time he was medically evacuated to Brisbane on 27 August – four days after first presenting to the medical clinic – his condition scored 3 out of 15 on the Glasgow coma scale, the lowest possible result while still alive. On 2 September, Hamid was declared brain dead. His family in Iran were contacted to give permission for Hamid’s life-support machine to be switched off. At 7.25pm on 5 September, Hamid died (Coroners Court of Queensland, 2018: 66).
Hamid had first arrived in Manus as a fit, healthy young man. The Coronial Inquiry found that Hamid’s death was preventable. However, rather than being attributable to one single error, his death was the outcome of a series of ‘little disasters’ and a ‘cascading litany of mistakes’ (Coroners Court of Queensland, 2018). It was clear that some medical staff on Manus were concerned to get Hamid to proper care but were confounded by a litany of bureaucratic missteps and miscommunications. All it needed, recounted Dr Glied, for ‘a strong man - a young man - who … did not have any past relevant medical history’, who did not have a cardiac problem or a disability, who was, ‘just a few days before or a few weeks before, a healthy strong man … [were] a lot of little disasters, following one after the other, none of them caught up and resolved, for it to finally to end up in a major disaster’ (Coroners Court of Queensland, 2018: 65). Despite this, the then Minister for Immigration and Border Protection, Scott Morrison, described the standard of care received by Hamid as ‘outstanding’ (Doherty, 2014). The government failed to acknowledge responsibility (Robertson, 2018). 7
The dressmaker from Italy: Nancy (Annunziata) Santoro and the cumulative effects of inaction
Nancy was born in Italy in 1924, migrating to Australia in 1956, where she worked as a dressmaker. She lived in her later years with her daughter, Anna. Sometime before admission to the RACF run by Assisi Aged Care, she was diagnosed with dementia, type 2 diabetes, arthritis and arrhythmia. Her eyesight and health were deteriorating, and she required a higher level of care than her daughter could provide. At the time of admission in 2017, she was nonetheless described as being in reasonable health for her age. Her health subsequently declined rapidly and she lost weight. She suffered a number of falls and was often heavily sedated, a factor noted as likely to increase the chance of falls (Tracy and Briggs, 2019a: 3099).
Nancy was admitted to hospital in July 2018, for treatment of a broken hip sustained after one of many falls, with surgical staples inserted during the operation. The staples were not removed until the wound subsequently became infected; Nancy was readmitted to hospital for removal of the staples on 6 August 2018 and then suffered from a pressure wound on her foot that became infected. As a diabetic, with poor circulation and weight loss, ‘any pressure injuries of this nature required careful and prompt treatment by the care staff at Assisi. That did not occur’ (Tracy and Briggs, 2019a: 3041). After the hip operation and on her return to the RACF, her doctor, Dr Tay, stated that he examined her each time he visited. But he did so without noting the foot wound, because, as he recounted, she would have footwear on, and there were no nursing records of the wound for him to consult (Tracy and Briggs, 2019a: 3116). The wound, which progressively worsened over many weeks, was largely ignored due to poor record keeping and an evident lack of commitment to the standard of care that might promote Nancy’s well-being. There were no formal records entered of observations made of heel wound between September 3 and September 17 until some weeks after initial observations were made.
Dr Tay testified to the Royal Commission that he was first verbally alerted to the heel wound on 13 September by nursing staff who ‘introduced the wound to me as ‘“Can you please have a look at this. This has been here for a little while”’ (Tracy and Briggs, 2019a: 3117). At that time, he classified the heal wound as grade 1 or 2 on the infection scale. However, the wound had been there for many weeks prior. The next time Dr Tay checked it was on his return from leave on 3 October. As Rozen went on to note, the records indicated that by this time: The wound site is open to 50 cent size. The wound is stage 3 and black in colour. Note left for GP to review (Tracy and Briggs, 2019a: 3143).
Accordingly, the doctor was relying on records he could not access until it was too late to undertake adequate preventive action. As noted, by this time it was described as ‘black’, despite all prior notes recording the wound as pink in colour and ‘coming along’ Tracy and Briggs, 2019a: 3158). In response to questions by Counsel Peter Rozen, for the Royal Commission, regarding record-keeping of the wound, Paul Cohen, CEO for Assisi Homes agreed that had there been timely entries made about the deterioration of the wound, it was likely that his would have triggered intervention by a wound specialist (Tracy and Briggs, 2019a: 3160).
By 9 October, with the wound having already been described as stage 3 and becoming necrotic, a wound specialist was finally called. The wound had deteriorated to the point where there was ‘significant depth with likely bony involvement’ (Tracy and Briggs, 2019a: 3042). Necrotic wounds indicate the ‘death of healthy tissue’ which is ‘almost always detrimental to the patient’ and potentially fatal (Kelso, n.d.). There was evidence of osteomyelitis, a bone infection, with the wound by now classified as being at stage 4, the most serious stage of injury: it was possible to ‘see and feel bone’ (Tracy and Briggs, 2019a: 3042). Osteomyelitis is a rare but serious condition, beginning in one part of the body before spreading through the bloodstream into the bone (Gottlieb, Atkins, and Shaw, 2002). Worse news followed. On 11 October, nursing staff reported to Dr Tay that eight maggots were found in Nancy’s heel wound by care staff. Nancy’s treating doctor was encouraged by nursing staff not to disclose this to her family (Garrick, 2019).
In the Commission hearing, CEO of Assisi, Paul Cohen, agreed that ‘there were significant gaps in the care provided …[that] departed from relevant guidance, procedure or policy documents in place at Assisi’ (Tracy and Briggs, 2019a: 3147). This included ‘undue waiting times’ for medical attention, the untimely removal of hip wound staples, unmonitored weight loss, unexplained medication changes, poor wound management and record-keeping, and poor pain management (Tracy and Briggs, 2019a: 3148). In a report tendered to the Commission, it was noted that ‘medical and specialist intervention was delayed until the stage of the wound was irreversible’ (Tracy and Briggs, 2019a: 3043). The extent of poor care was not simply the failure to see the wound as sufficiently serious to warrant immediate and careful attention. In addition to this, the care which Nancy did receive was mechanistic and unresponsive to her needs. She continued to be subjected to physiotherapy even though this also worsened her condition, leading to greater pain (Tracy and Briggs, 2019a: 3042).
Despite the clear breaches of procedure, the CEO Cohen nonetheless concluded that: … the care provided to Mrs Santoro met the processes, policies and procedures that were in place at Assisi at the relevant time (Tracy and Briggs, 2019a: 3149).
Just four weeks later, the Assisi facility was assessed as ‘meeting the quality standards for clinical care and skin care’ (Tracy and Briggs, 2019a: 3043).
Nancy’s death certificate found seven causes of death, including the failure to treat the foot wound and the untimely removal of a surgical staple from her infected hip (Tracy and Briggs, 2019a: 3043). Although Nancy was vulnerable to infection as a result of prior medical conditions, her vulnerability was also produced by the conditions of her confinement (Dehm et al., 2021: 70–71) leading to progressive deterioration and increasing dependence on critical medical care.
Paradoxically, the system failed Nancy because of what it has effectively been purposed to do: the capacity for care has diminished with the move towards privatisation under the
Such a pattern of neglect was found to be so widespread in the aged care sector that the Royal Commission’s Interim Report was simply titled aged care system fails to meet the needs of our older, often very vulnerable, citizens … In too many instances, it simply neglects them (Tracy and Briggs, 2019b: 1).
This pattern appears unresolved despite increased attention on practices of neglect in the sector: two years later, in September 2020, reports emerged that George Osgood, a former resident of the Tenison Residential Aged Care Swansea in New South Wales, Australia, had died from infected foot wounds resulting from a staphylococcus infection, 51 days after he became a resident there (Wakatama, 2020).
Zones of neglect
It is in dwelling at length on the unfolding of events leading to the deaths of Nancy and Hamid, that the quiet horror of their deaths is revealed, from the untreatment of what began as skin wounds, through myriad, small inactions that characterise patterns of conduct in these sites. Elsewhere, for example, rather than scenes of immediate violence and brutality, studies on what is colloquially referred to as ‘The Jungle’ – a cramped and squalid refugee camp in Calais (Davies et al., 2017; Mayblin et al., 2020) and on power exercised at the border in the Australian and broader context, point to neglect as a form of power, even if not explicitly describing it as such (Dehm, 2021; Pugliese, 2009). Refugees in the camp at Calais have lived in cramped and damp living quarters, with limited access to washing facilities, resulting in ‘untreated infections’, infestations, and ‘viral, bacterial, and psychological illnesses’, some ‘reaching epidemic proportions’ (Davies et al., 2017: 1277). For Thoms Davies et al. (2017) these settings are akin to what Mbembe describes as ‘deathworlds’, places where bodies are barely kept alive, subjected to violence which is indirect but ‘in no way abstract’ (Davies et al. 2017: 1280). Like Nixon’s slow violence (2011), the impact of such suffering often unfolds in a delayed or less explicit way, making it ‘hard to articulate’ (Davies et al., 2017: 1278).
In withdrawing or limiting adequate care and support, these sites harbour the potential to become necrositic, in which death is always immanent as an effect of a person’s location there. In the Australian context, Suvendrini Perera (2002), Joseph Pugliese (2009) and Maria Giannacopoulos (2021) have shown how the function of the refugee camp is implicated in broader structures of settler colonial violence as an exceptional space which has a long and normalising history, functioning as the ‘border zones of the dead’ (Pugliese, 2009). 8 In their work on ‘deathscapes’ – places of racialised, colonial harms – Pugliese and Perera reflect on how ‘graphic instantiations of law’s epistemic violence’ emerge in even the ‘seemingly most routine practices and procedures’ (Pugliese and Perera, 2018). Practices of neglect are illustrative of such routinised violence. In describing both aged care and immigration detention sites as ‘necrositic’, I emphasise the particular features they embody, whether within or outside the legal order. The term necrositic also invites us to reflect upon necropower and how this structurally enabled by the characteristics of specific locations (Minca, 2006). The death resulting from the neglect accompanying many small inactions, reveal aged care and immigration as particular manifestations of ‘deathworlds’ or ‘deathscapes’. Rather than places of explicit violence however, they function as zones of neglect. Nancy and Hamid inhabited settings akin to what Elisabeth Povinelli (2011) has called the ‘economies of abandonment’, segregated in conditions confining them to the status of mere body. 9 Following Agamben, those who are ‘banned’ in this way, are not so much beyond the law, as ‘abandoned by it, that is, exposed’ (Minca, 2006: 391). Importantly, the suffering endured by those abandoned, tends to be ‘ordinary, chronic and chruddy rather than catastrophic, crisis-laden and sublime’ (Povinelli, 2011: 3). Despite the apparent rapidity of Nancy and Hamid’s decline, their deaths were the effect of their prolonged invisibility as agential human rights subjects. These were ‘quiet’ deaths (Lamble, 2013: 144) produced by prior, compromised well-being as an effect of confinement (Coroners Report of Queensland, 2018: 13).
However there was no
‘Letting die’ is then, ‘an active inaction’ (Tyner, 2016) the full impact of which is ‘concealed within the “hidden violence of abandonment”’ (Davies et al., 2017: 1269). As an action produced through inaction, neglect remains the failure to care for someone for whom we have responsibility. Here I mark a distinction between what I call
Conclusion
Despite neglect (when understood as negligence) suggesting a failure to meet responsibilities in law, it tends to attract lower levels of accountability than the direct hit of physical violence (Bhatia, 2020: 282). Services are merely withdrawn or not offered at all. Yet inaction remains a form of power. Violence is relocated in ways that not only create an inverse relationship between power and responsibility but place the responsibility with those who have neither power nor control, while eradicating responsibility from those exercising it and from the structures that generated it. In its summary of the causes of Hamid’s death, the Coroners Court of Queensland (2018: 4) asserted the systemic causes of death, rather than allocating responsibility to a particular individual, and concluded that Hamid’s death was rendered comprehensible ‘in the broader context of Australia’s immigration policy framework’. Likewise, the Royal Commission into Aged Care Quality and Safety (Tracy and Briggs, 2019b) described aged care as characterised by systemic neglect, leading to avoidable harms. Legal counsel appearing at the hearing into Nancy’s death, Peter Rozen, referred to ‘a pattern … of poor care and at some levels an unwillingness to accept responsibility for that despite the refusal by the quality and risk manager that “this was not a systemic failure”’ (Tracy and Briggs, 2019a: 3162–3163). Both findings dilute the ability to hold one person accountable, as we saw in the respective refusal of government ministers or of the CEO of Assisi to admit responsibility for Hamid and Nancy’s deaths, notwithstanding the significance of the insistence on structural causes: these deaths were systemically produced.
In concluding, I wish to press the point that there is a conceptual and empirical utility afforded by drawing out the parallels between the deaths of Nancy and Hamid. This coalescence in practices across apparently diverse sites of confinement reinforces the need for vigilance on how the exception can mutate into new forms otherwise considered unimaginable (Agamben, 1999: 50; Pratt, 2005: 1055). Although appearing to be distinct, immigration detention and aged care converge as sites of segregation, control and neglect, whether for those who exist in a zone of exclusion, or for those who putatively enjoy the status of membership. What brings these two sites together is the way that, as spatial sites of segregation, the deathworlds they comprise can be understood as ‘zones of neglect’. This removes the state from direct accountability for the scene of death even while the organisation of death has become a function of the political (Mbembe, 2003: 7). Practices common to both arise from a diminished appreciation of these lives as lives worth nourishing. In Hamid’s case, Departmental officials were reluctant to take any action at all, in which his abandonment is explained as the effect of becoming the illegalised subject of domestic law. For Nancy, the loss of rights occurred more gradually, through the paternalism accompanying the gradual diminishment of her subjectivity. Both cases illustrate how responsibility is eroded through many small steps, and ‘non-action’ (Minca, 2005: 409) such as the denial of basic health care (Dehm, 2021: 347). This violence occurs behind a ‘veil of inaction’ (Davies et al., 2017: 1281) which functions to control and coerce (Davies, et al., 2017: 1281) at the same time that accountability for these harms is diminished. Despite evidence of limited attempts to treat and press for the need for better care, such responses either came too late, were poorly recorded, obstructed, or undertaken without due care. Yet there was an insistence by management and government that the sites in which Nancy and Hamid died, provided quality care. This insistence, and the failure to treat what were entirely treatable wounds, ultimately amounts to a refusal to see the other, and the injuries of the other that was bound up with the location in which they were confined: it was enabled through neglect as a function of power over those living in sites of confinement, regardless of whether purposed to deliver care or punishment.
Footnotes
Acknowledgements
I wish to extend my thanks to all of the participants at the University of Melbourne 2019 Workshop 'Confinement: Spaces and Practices of Care and Control', whose rich contributions provoked much of the thinking in this paper. I am also grateful to the feedback from those attending the 2019 'Colloquium: The Scene and the Unseen', convened by the University of Melbourne, with colleagues Associate Professor Juliet Rogers and Professor Alison Young, where I presented a version of this work. I also gratefully acknowledge Dr Diana Johns, Dr Emma Russell and Dr Micaela Sahhar for their helpful comments on article drafts. Lastly, I wish to thank the anonymous reviewers, whose feedback made this a much better article than it would otherwise have been.
Declaration of conflicting interests
The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author received no financial support for the research, authorship and/or publication of this article.
