Inquest into the death of Robert Elan Peihopa

Contributing factors

• Chronic coronary artery disease (80-90% narrowing of right coronary artery)
• Ingestion of methamphetamine (toxic levels: 1.8 mg/l) in hours before death
• Physical fight immediately prior to death
• Emotional and physical stress from altercation
• Inadequate supervision allowing 17-minute delay in detection of collapse
• Lack of information sharing about known drug history

Coroner's recommendations

1. The Department and Serco should each review the circumstances of this matter and give consideration to whether two Detention Service Officers in the Mitchell Compound is sufficient to provide an adequate level of supervision and security.
2. The Department should liaise with International Health and Medical Services about developing and making available at Villawood Immigration Detention Centre a rehabilitation program specifically targeted at ice users.
3. The Department should investigate ways to facilitate drug and alcohol rehabilitation programs being provided to detainees who require them.
4. Search and seizure powers available at immigration detention facilities should be enhanced to (a) prevent the entry of illegal drugs into immigration detention centres and (b) detect illegal drugs which have entered immigration detention centres.
5. The Department and Serco should review their procedures to facilitate greater sharing of information about suspected drug and alcohol use by detainees with staff members who have supervision or welfare responsibilities towards those detainees.
6. Serco should review the way in which it manages intelligence holdings suggesting detainees are using illegal drugs or alcohol in order to ensure that adequate supervision arrangements are in place in relation to such detainees.
7. The Department should investigate with NSW Corrective Services and NSW Justice Health options for obtaining information from them about a detainee's custodial history including information regarding their behaviour whilst in custody, health and welfare and any history of drug and alcohol use, and options for making this information available to both Serco and IHMS.
8. The Department and Serco should develop a protocol which: (a) clarifies their respective roles in enquiring into the background and circumstances giving rise to a Critical Incident; (b) clarifies the means by which they will keep abreast of developments of any police investigations.
9. The Department and Serco should develop a protocol for notifying in a timely manner the next of kin of the death of a detainee, and a representative of both the Department and Serco should communicate with the next of kin to acknowledge with appropriate sensitivity the death of their loved one while in Serco and the Department's care and control.