Death behind high walls and carefully scripted statements

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It was disturbing to read that there will not be a coroner’s inquest into the case of Dinesh Raman Chinnaiah who died inside Changi Prison on 27 September 2010.

Responding to queries from The New Paper, an [Attorney-General’s Chambers] spokesman replied in an e-mail: “In view of the conclusion of criminal proceedings, the inquiry has been discontinued.”

— 24 July 2013, The New Paper, Coroner’s Inquiry into prisoner’s death stopped

It is common practice, I would have thought, that any death in unclear circumstances would need a coroner’s inquiry to establish the cause of death. Such a process, open to the public, ensures transparency in the interest of justice. Although it is not the purpose of an inquest to establish liability, the inquiry, based on witness and expert evidence, would be able to point to potential defendants.

Such a process helps ensure that the right persons are charged, and with an appropriate level of potential culpability.

As it turned out in this case, it was all over in an afternoon. Deputy Superintendent of the Prison Service Lim Kwo Yin, 36, pleaded guilty to causing the death of Dinesh through negligence. The judge said he “did not adequately observe the acts of restraint” after Dinesh hit another warden in the abdomen. Lim was fined $10,000 and has been transferred to a desk job (Source: Channel NewsAsia. Link)

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The prosecution provided a timeline of events and the mainstream media carried it almost word for word. But without a coroner’s inquest, the public has not had a chance to hear the originating witness testimony as to what exactly happened. We only have the prosecution’s version. It is therefore hard to judge if the charge that Lim faced was too heavy or too light, if the fine was appropriate, or whether other wardens who were involved that day were also culpable to a degree.

A foreign friend remarked to me yesterday that there was no way the government would prefer a charge against Lim that would send him to jail. His life might be in jeopardy should he be locked up alongside inmates whom he used to lord over. This, with the implication that Lim has enjoyed special leniency, is of course an entirely speculative comment, but it goes to show how the lack of transparency leads people to ascribe ulterior motives to officialdom.

The timeline as provided by Today newspaper, which I reckon was read out by the prosecution in court, goes like this:

Around 10.45am, Dinesh Raman Chinnaiah is outside his cell; it’s part of the day’s routine. He kicks prison officer Sergeant Lee Fangwei Jonathan in the abdomen. Other wardens respond to restrain him and pepper spray is used. Senior Prison Officer Lim Kwo Yin supervises the operation.

Dinesh Raman is taken to a solitary cell, where he is placed in a prone position, i.e. chest and abdomen down. His face, says the prosecution, is turned sideways. Lim fills a pail of water to “de-contaminate the prisoner”, presumably of the pepper spray.

Then officers leave Dinesh. The timeline says he was “unresponsive” even then.

At about 11.18am, “shortly after he leaves the cell, Lim re-enters and finds Dinesh Raman unresponsive.” Lim calls for medical assistance, an attempt at CPR is made on the spot and Dinesh is sent to Changi General Hospital.

At 12.45pm,  Dinesh is pronounced dead.

The timeline says “he died of breathing difficulties from being in a prone position.”

Immediately I can think of several questions to ask. For example,

  • How many officers participated in restraining Dinesh?
  • Did any officer hold him with a chokehold around the neck at any time?
  • How much pepper spray was used, from what distance, and what were the guidelines for its use?
  • The timeline says his face was turned sideways when he was laid in a prone position. Did the post-mortem medical examination find evidence to support this assertion (generally the pooling of blood when a person dies indicates the posture he was in at the time of death)?
  • Why does it say that Dinesh was “unresponsive” even before Lim and his officers left him alone in the cell?
  • How did they test for unresponsiveness? Were they not disturbed even then?
  • Was the amount of water used and the method (not described, but one imagines the officers just throwing the entire pail at Dinesh) sufficient to wash off the pepper spray? What were the guidelines?
  • Why is the cause of death — “breathing difficulties” — so vague? Isn’t it obvious that many things can cause breathing difficulties and one needs to get to the bottom of it?
  • Was it the effect of pepper spray? Did he drown? Had he been asphyxiated by a chokehold way earlier?
  • Were there any bruises on his body that might be indicative of excessive force used on him, e.g. broken ribs and punctured lungs?

As you can see, a quick rush to judgement is hardly satisfactory.

It is true that many cases of unnatural death are not followed by coroner’s inquests. We hardly ever hear of such proceedings when murder is committed, for example. But some causes of death are far clearer than in Dinesh’s case. If a victim is stabbed several times or run over by a truck, it is pretty easy for a medical examiner to determine cause of death.

pic_201307_12But several things happened to Dinesh, which in the normal course of events should not cause death. Yet he died. Moreover, it happened in a prison, which makes his case a matter of considerable public interest, unlike say, a domestic dispute that results in someone bashing the spouse’s head in. So all the more, the state should have bent over backwards to hold a public coroner’s inquest before rushing to charge Lim.

The state may argue that Lim was free to contest the prosecution’s case at the trial, and if he chooses to plead guilty, which he did, it means there is no issue with the timeline as provided. That glosses over the real question. Lim had a variety of reasons to plead as he did; it may just be more convenient for him. His action is hardly the final measure of the substance and credibility of the timeline.

Only a proper coroner’s  inquest that does not seek to pin liability and is thus carefully devoted to fact-finding can provide the credibility our authorities crave. But do not achieve.

Bertha Henson on the Breakfast Network raises similar questions: Just how did Dinesh die? and Just how did Dinesh die, part 2?

30 Responses to “Death behind high walls and carefully scripted statements”


  1. 1 solven 25 July 2013 at 23:44

    So what if a coroner’s inquest is carried out? When the state is intent on hiding something, there is nothing you can do about it, short of changing the government. Haven’t Shane Todd’s case taught us something?

    • 2 jaochoui 29 July 2013 at 14:46

      Why are we so sure there was anything to hide? Yes, more should have been done, but if we do not wish conclusions (or judgements) to be made quickly by others, let us not do it ourselves.

  2. 3 lolwut 25 July 2013 at 23:55

    Water, by itself, won’t get rid of pepper spray. At the very least you’d want some soap to go along with it – though perhaps soap was mentioned, or that it was tacitly understood that soap would be involved.

  3. 4 Anon 4s44 26 July 2013 at 00:24

    AGC’s response:
    http://news.asiaone.com/news/singapore/agc-clarifies-why-no-coroners-inquiry-was-held-prison-inmates-death

    “This discretion conferred on the Coroner by section 39 of the Coroners Act ensures that while all unnatural deaths are investigated and looked into, there is no multiplicity of proceedings that would be a drain on the state’s resources.”

    This makes it even more scary. There are actually laws written that dispense the need for a Coroners’ inquiry. So it just means, don’t end up in prison ever… best advice?

    • 5 teo soh lung 27 July 2013 at 11:22

      The accused pleaded guilty to the charge. Technically, there was no finding by the court which did not hear evidence from witnesses. The coroner should have proceeded with the inquiry to determine the cause of death and who else were involved. I read that 8 officers were involved in subduing the young man. Prima facie, I would conclude that there was excessive force. Even two prison officers who are all trained in martial arts would be more than sufficient to put down an unarmed “violent” inmate. And yes, it is scary that the law provides exemptions.

  4. 6 Anon uoCt 26 July 2013 at 01:37

    Hi, I think this is a great article and my heart goes out to Dinesh and his family, but it’s not quite right to make light of family violence either. A domestic dispute is and should be a matter of considerable public interest, especially if someone’s head gets bashed in. Violence in the home is the same as violence anywhere else.

  5. 7 Ziggy 26 July 2013 at 05:18

    Another question to consider:

    Was water found in Dinesh’s lungs?

    Could the pail of water have been used for something more sinister?

    • 8 david 26 July 2013 at 14:23

      Why is there no video camera footage ? Prison tend to have video camera place all over the place. Is there no video footage or is it due to reason, the camera not working at that particular moment ?

  6. 9 Keh Lip Sih 26 July 2013 at 11:14

    So whats the point in this article this time? I find it disrespectful to the family. Now that all the dirt has come out about Dinesh having a part in family violence and all these. I thought we could have respected that…at least some dignity was preserved. Now, we will start hearing how he has a history of violence blah blah..but for godness sake, he’s passed on, respect the family pls Mr. Author. The cause of death was difficulties in breathing, which was established, what else do we need to coroner on? Did the family request for one? Pls, be sensitive.

    • 10 GoonDoo 26 July 2013 at 17:00

      Keh Lip Sih:

      The point of the article is simple – to give complete closure to the deceased’s family. I’m sure they have themselves many unanswered questions, which a coroner’s enquiry would/could have addressed. They would be given an opportunity to ask burning questions.

      The cause of death was breathing difficulties – but you forget to ask, how did the breathing difficulties come about?

      Regarless of whether the family asked for a coroner’s enquiry or not. what Alex raises is a PUBLIC INTEREST question for the good of the public at large…

    • 11 yawningbread 26 July 2013 at 21:56

      By any chance is this a “let’s help the government” attempt to stifle discussion on this subject?

    • 13 Singapore Deserves Better 27 July 2013 at 08:01

      Keh Lip See, we all respect the family. Everyone wants proper closure when a loved one dies. Here, there is a chance that foul play is being hidden and covered up. Would you want someone who killed a member of your family to get away by being fined $10,000? It’s all about JUSTICE! Think about it!

  7. 14 Dumb Investor 26 July 2013 at 14:32

    Recently a few officers from the Malaysian Police were found guilty for the death of the young Indian man called Kugan. That case when to court because of public pressure. I am sure nothing of this sort will happen here, with the case receving so little press coverage. As we all know the AG has much more important matters, like charging cartoonist, to be worried out strange deaths in prison. That’s what I call a first world legal system

  8. 15 JG 26 July 2013 at 15:28

    Unfortunately, the bigger issue is this – Most Singaporeans don’t care about the plight of prisoners / foreign workers / maids / s377A / ISA detainees etc. ie. the down-trodden of society. The State can commit whatever abuses it want (within limits) and get away with it because Singaporeans do not really care. And the Govt knows it. So it issues a wayang report, case closed, and no one bats an eyelid.

    In a way, we get the Govt we deserve — the Govt only cares about GDP growth, because the bottomline is that economic welfare is what most Singaporeans only care about.

    Happy National Day .. a great case to hold a mirror to the real face of Singapore.

  9. 16 passerby 26 July 2013 at 16:07

    If you read ST, the specific cause of death was found to be “positional asphyxia”, which rules out pepper spray, chokeholds, water being the cause.

    http://en.wikipedia.org/wiki/Positional_asphyxia

    • 17 yawningbread 26 July 2013 at 16:40

      “Positional asphyxia” suggest that he was face down. His face would have been pressed to the ground such that he couldn’t breathe. This raises even more questions! The prison officers say his head was turned to the side — according to the prosecution statement. So, why the contradiction?

      Or was he already dead by the time the prison officers turned his face to the side? Remember, the officers said that he was “unresponsive” after splashing water on him. And yet, they left. Bertha Henson in her Breakfast Network article asks if during the restraining operation, did anyone sit on Dinesh to force him to the ground? E.g. were hands place over the back of the neck or head to keep the head down and if so, how much force was used? In forcing him down, they could have pressed his face to the ground long enough to have killed him. The implied suggestion in the prison officers’ statement that he was alive when they washed him (even though “unresponsive”) may mean less than it looks.

    • 18 shane 26 July 2013 at 19:49

      You are really a twit. Positional asphxia means one is prevented from breathing by undue and forceful restraint. This is not much different from strangulation and manslaughter. Big words are used just to fool the public like you.

      [Yawning Bread: I delete personal attacks. If deleting is too tedious, I will simply trash the entire comment.]

      • 19 teo soh lung 27 July 2013 at 11:28

        Just wondering if his hands and legs were shackled when he was on the floor. Otherwise, he could have got up if he was conscious.

  10. 20 Ben Thambiah 26 July 2013 at 16:23

    No coroner inquiry… 5-8 men to restrain a relatively skinny looking boy… Pepper spray… Positional asphyxiation…

    Was there any evidence of abuse to the boy? Can the family sue to find out the truth?

    Or, as I expect, will he be disregarded and forgotten because he looked like a ‘gangsta-kid’, who if alive wouldn’t have amounted to much anyway.

    • 21 Sgcynic 27 July 2013 at 08:45

      8 men to restrain one slim prisoner. Just imagine if it were a couple prisoners who were unruly, what would it take? Turn out the entire prison barracks and still be short-handed? Isn’t this a farce? Or simply overkill? Without a coroner’s inquiry, some could simply think 8 men had their fun, and one took the fall. Credibility of the SPF, home team, entire public service at stake given the repeated high profile cases that are being uncovered. The governing party’s credibility and integrity has already been eroded, now it’s the public service’s turn. The rot has spread..

    • 22 Sgcynic 27 July 2013 at 08:50

      When it comes to the integrity of the institutions, it is not simply a matter of suing the individual for contempt of subjudice. This simply will not do. We have a string of personnel in high places who are charged, ex-MP, high ranking officers from the CD, SPF, CPIB. When it is pervasive and even the wardens are corrupted, it is indeed systemic

  11. 23 Thor 26 July 2013 at 16:27

    I have been disturbed by this over the last few days. How come no body else seems bothered in our country? What about the ministers from the community? Is a life worth $10 000 only? What are the repercussions of this? Will another warden not think twice of similar restraint on prisoners knowing any mistake leading even to loss of life might be explained away and settled with a fine? Will the state pay compensation to the family? Will the home minister apologize for the fatal mistake on his watch?

  12. 24 Chanel 26 July 2013 at 17:32

    There is no transparency, so how can the government blame us for speculating?? Will AGC now charge Alex for contempt of court?? The usual tactic of silence the population?

  13. 25 Woo 26 July 2013 at 17:33

    If you have someone heavy sitting on your upper back while you are in a prone position, your chest may not be able to expand thus limiting air into your lungs. We used to do this to our buddies in NS as a prank and I experienced 1st hand how difficult it was to breath when others are stacked on top of you, even for a few seconds.

  14. 26 a kind of chicken 26 July 2013 at 17:43

    Hi alex au,

    Your blog is an invaluable service for our country. If we ever see a new Singapore, it will be in large part due to people like you. Kudous and respect.

    Yes, it disturbs me too. It seems that if one is poor or powerless, it seems possible that ones life is not even protected by the law…. This is not the first case (see shane todd) and there are an increasing number of murders, “suicides”. As you say, without greater transparency there is a deep worry about systemic problems within our system.

    • 27 Du La 27 July 2013 at 13:23

      Totally agree that this is a sad case of poor being powerless and their interest not looked after….
      This case really disturbed me for 2 reasons:
      1. Authorities have the power to conveniently sweep things under the carpet without full accountability

      2. Singaporean as usual minding their own business as long as they are not involved… Neglecting the big picture that we are being short changed for our rights….

      How are we going to be 1st world when the authorities such unchecked power over us

  15. 28 Josh 27 July 2013 at 00:07

    Overheard from an officer in prison, they emptied an entire bottle of pepper spray on his face, when he was “chicken wing-ed” (being restrained/shackled with arms and legs to the back). He was apparently dragged in this position to PC (Punishment Cell) and left on a “prone” position. (Still shackled, which they failed to mention…)

  16. 29 Lye Khuen Way 27 July 2013 at 07:47

    So the Prison Service is a State within a State just like the State Coroner is a Judge acting on his State given discretion. No Goverment or a Totalitaian State ? Or as I like to put it, a coverment ?

  17. 30 Stuly Kan 28 July 2013 at 05:53

    Die within 24 hours of surgery = coroners inquiry
    Die within 24 hours of hospital admission = coroners inquiry
    Healthy 21 y old man Die immediately after being restrained in prison = ?


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