Inquest into the death of Leah Jane Porter

Contributing factors

• borderline personality disorder
• ADHD
• treatment-resistant depression
• severe mental health disturbance
• high medication non-compliance
• lack of psychiatric continuity
• inadequately individualised support plans
• high stress from kitten removal
• non-ideal detention environment for mental health treatment
• inadequate staff training in mental health recognition
• insufficient monitoring adjustments for behaviour changes

Coroner's recommendations

1. Commonwealth revisit processes for considering and implementing reviews of immigration detention, and assess whether improvements are needed
2. Commonwealth implement specified timeframes for responding to recommendations from such reviews
3. Commonwealth commission independent study to identify reasons why detainees do not routinely take mental health medication or attend scheduled medical appointments
4. External auditor conduct audit of VIDC to identify hanging points and features that could be used for self-harm
5. Commonwealth ensure recommendations are implemented by any successor organisations to Serco and IHMS
6. FDSP staff be trained in responsibilities pursuant to PSP/SME Plans and recognition of mental health illness signs and deterioration
7. FDSP staff performing welfare checks undergo training in best practice for welfare checks of detainees
8. Serco Personal Officers receive further training in requirements of their role
9. DHSP staff be trained in best practice preparing PSP/SME Plans, including tailoring plans to specific detainee circumstances and communicating clear instructions to FDSP staff
10. Commonwealth and DHSP expedite development of memorandum of understanding regarding admission/discharge processes and mental health services at VIDC
11. Commonwealth obtain clinical recommendations for improvement of Behavioural Management Plan from IHMS and successor organisations