Inquest into the death of Moses Kellie

Case Number: 2019/00028070

Date of Findings: 6 March 2025

Magistate: Deputy State Coroner, Elizabeth Ryan

CORONIAL LAW – death of a person in immigration detention – were mental health care services adequate – was monitoring by detention staff adequate - is there a need for improved system for information sharing – are measures to reduce the risk of hanging adequate – did the person receive adequate mental health care in hospital.

Responses

Recommendations

To the Department of Home Affairs

1.  That the Commonwealth revisit its processes for considering reviews of the immigration detention process commissioned by, or available to, the Commonwealth, and for implementing any recommendations made in such reviews and consider whether any improvements to those processes are required. 
2. That the Commonwealth implement a specified timeframe for responding to any recommendations made in any review referred to in the recommendation above. 
3. That the Commonwealth amend the 2023 Procedural Instruction to require non-mental health clinicians employed by the Deployment Health Surveillance Program (DHSP) and employees of Facilities and Detainee Services Provider (FDSP) to have access to advice provided by a mental health clinician 24 hours per day and 7 days per week.
4. . The Commonwealth make a decision on the ASR submitted by International Health and Medical Services (IHMS) requesting funding for a mental health nurse to be available on the HAS line 24 hours per day (assuming that this has not already occurred).
5. That the Commonwealth ensure that, as far as is reasonably practicable, to the extent that any of the above recommendations are directed to Serco and/or IHMS, those measures are implemented by any organisation that may succeed Serco as FDSP and IHMS as DHSP.
6. That the Commonwealth consider commissioning an independent study to identify the reasons why detainees in Villawood Immigration Detention Centre (VIDC) do not routinely take their mental health medication.
7. That as a matter of priority, the Commonwealth: 
• extend its ‘ligature review’ (referred to in its submissions in the inquest into the death of Mr Moses Kellie) to all accommodation and bathroom areas within the VIDC as part of an Administrative Capital Works project; and 
• commit to taking reasonable steps to remove ligature points identified in the ‘ligature review’ 

To Serco Australia Pty Ltd, or the detention service provider which replaces Serco Australia Pty Ltd

1. That FDSP staff be trained: 
• in their responsibilities pursuant to a PSP/SME Plan; and
• as to the recognition of signs and symptoms of mental health illness and/or deterioration. 
2. That FDSP staff whose role includes performing or supervising the performance of welfare checks undergo training as to best practice in performing welfare checks of persons in immigration detention.
3. That Serco Staff who undertake the role of a “Personal Officer” receive further training as to the requirements of fulfilling the role of a “Personal Officer” in the Personal Officer scheme referred to in Serco Policy and Procedure Manual 0001- Keep SAFE and PSP/SME, 30 April 2020.
4. That the training referred to in Recommendations 9 and 10 be provided by an external consultant

To International Health and Medical Services Pty Ltd or the health services provider which replaces it

1. DHSP staff be trained as to best clinical practice in preparing a PSP/SME Plan with such training covering, in particular, the following topics: 
• the importance of tailoring an SME Plan to the specific circumstances of a detainee; and 
• the importance of communicating clear instructions to FDSP Staff (and to other persons who have responsibilities for implementing the measures contained in a PSP/SME Plan).

To the Department and IHMS or the health services provider which replaces it

1. That the Commonwealth and the DHSP expedite the development of a memorandum of understanding with South Western Sydney Local Health District regarding:
   • the process for admitting and discharging a detainee from hospital; and
   • the mental health care services that are to be provided to a detainee at VIDC.