Inquest into the death of Leah Jane Porter

Findings and Recommendations

Findings and Recommendations of Inquest

Case Number: 2022/00148393

Date of Findings: 6 March 2025

Magistrate: Deputy State Coroner, Elizabeth Ryan

CORONIAL LAW – Death of a person in immigration detention – intentional self-inflicted death – where deceased died by hanging whilst in lawful custody – appropriateness of care and treatment provided to persons in immigration detention by relevant service providers – non-compliance with medication in immigration detention – whether detention service providers are sufficiently trained in mental health treatment – whether sufficient measures are taken to reduce risk of detainees suiciding - changing nature of immigration detention population.

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 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.

4. That an external auditor conducts an audit of VIDC with a view to ascertaining the existence of any hanging points or features in the physical design of the premises which could be used by detainees to self-harm.

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 International Health and Medical Services (IHMS), those measures are implemented by any organisation that may succeed Serco as Facilities and Detainee Services Provider (FDSP) and IHMS as Deployment Health Surveillance Program (DHSP).

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

6. That FDSP staff be trained: 

The International Health and Medical Services Pty Ltd (IHMS) or the health services provider which replaces it:

9.  DHSP staff be trained as to best practice in preparing a PSP/SME Plan with such training covering, in particular, the following topics:

a) the importance of tailoring an SME Plan to the specific circumstances of a detainee; and 

b) 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:

10. That the Commonwealth and the DHSP expedite the development of a memorandum of understanding regarding: 

a) the process for admitting and discharging a detainee from VIDC; and 

b) the mental health care services that are to be provided to a detainee at VIDC.

11. The Commonwealth is to obtain clinical recommendations (made by appropriately qualified mental health clinicians) from IHMS and any organisation who might succeed IHMS in the role of DHSP for the improvement of the Behaviour Management Plan (BMP) such that it is a program that can be fully endorsed by the DHSP to achieve its intended operation in relation to detainees for whom clinical input is appropriate.