Monday, December 19, 2011 » 10:17pm
Authorities failed in their duty of care to three detainees who took their own lives during a three-month period at Sydney’s Villawood Immigration Detention Centre, a NSW coroner says.
State Coroner Mary Jerram listed systemic failures by the Department of Immigration and Citizenship (DIAC), Serco Australia Pty Ltd (Serco) and International Health and Medical Services Pty Ltd (IHMS).
The department outsources management of detention centres to Serco and provision of health services in the centres to IHMS.
‘In all three deaths, some of the actions of some staff were careless, ignorant or both, and communications were sadly lacking,’ Ms Jerram said on Monday at Glebe Coroners Court.
She referred to ‘startling examples of mismanagement’, the inadequacy of staff training and the ignoring of policies and protocols.
Ms Jerram made a string of recommendations covering matters such as case management of detainees and assessment of their risk of self-harm or suicide.
In her inquest findings on the deaths of Fijian citizen Josefa Rauluni, 36, UK national David Saunders, 29, and Iraqi Ahmed Al-Akabi, 41, she found all had taken their own lives.
Mr Rauluni died on September 20, 2010, after diving from a first-floor balcony railing onto concrete.
The day before he had faxed the Immigration Minister stating that if he was returned to Fiji, it would be his ‘dead body’.
Mr Al-Akabi died in November by hanging himself, and Mr Saunders used the same method in December.
The coroner said Mr Rauluni was reported to have been shocked and fearful when told on a Friday that he was to be removed from the country on the following Monday.
Ms Jerram recommended that DIAC should ban notifications of negative decisions on a Thursday or Friday, given that no mental health staff worked on the weekend.
She described as ‘chaotic’ the scene when Mr Rauluni was on the balcony threatening to jump.
People shouted at him to come down while he became increasingly upset, as seen in a DVD of the incident later reviewed by a psychiatrist.
The psychiatrist stated that that Mr Rauluni was clearly a high risk, the response to his situation lacked co-ordination and orderliness, and it was not clear who was in charge.
The coroner found that Mr Al-Akabi probably had a major depressive disorder but he was misdiagnosed, and his ineffective medication should have been discontinued.
Very little action or assistance was offered to him, she said, despite his making it clear to officials he was depressed and in a poor physical and mental state.
‘The seriousness of his mental state was not detected, documentation practices were extremely poor and there was a sad lack of continuity in (his) clinical care.’
She said of the three suicides, his was probably the most foreseeable and therefore, at least theoretically, preventable.
Mr Al-Akabi was not referred to IHMS for assessment or counselling after DIAC staff were told of his past attempt at suicide and recent threats to harm himself.
On November 25, he was placed on security watch, requiring observations every 60 minutes, but Serco officers were not aware of his suicidal risk.
CCTV footage showed he was not observed every 60 minutes on December 8. He entered the bathroom at 1.27am, and at 3.31am he was discovered dead by another detainee.
The coroner said detainees were obviously at much greater risk of suicide than the general community.
‘The corollary of that is that those responsible for detainees owe a greater than normal duty of care to those persons regarding their health and wellbeing.’
She found no one acted in bad faith deliberately, but ‘it is a failure of systems which in my view require remedy’.
Her wide-ranging recommendations included the revision of the policy relating to the use of force in effecting the removal of detainees and that IHMS notify DIAC and Serco in writing of the outcome of its risk assessments of clients.
Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14 or Suicide Call Back Service 1300 659 467