Inquest into the death of Jerwin Royupa

Contributing factors

• Inappropriate approval of Subclass 407 training visa by Department of Home Affairs
• Lack of supervision and monitoring of training visa conditions
• Exploitation of overseas trainee including excessive hours, non-payment, passport confiscation, isolation, and intimidation
• Inadequate supports and services available to vulnerable visa holders, particularly those experiencing exploitation
• Fear of sponsor and threat of deportation or police involvement
• Lack of clear pathways for reporting exploitation or modern slavery
• Inadequate initial police investigation failing to treat incident as suspicious
• Failure to engage crime scene and crash investigation resources
• Absence of inter-agency coordination regarding exploitation allegations

Coroner's recommendations

1. Minister for Home Affairs to conduct a thorough internal review (root cause analysis) regarding lessons learned from Jerwin's death, including consideration of: formal review process for DHA approval of s407 visas potentially used for exploitation; risk profiling to identify high-risk sponsors (new sponsors, geographically isolated agricultural areas, unskilled labour risk, small scale operations); random audits by Sponsor Monitoring Unit of high-risk sponsors; inter-agency referral and coordination regarding exploitation allegations; using the matter as a case study for officer training; review of visa grant letters and appropriateness of sponsor being sole authorized recipient of visa information
2. Minister for Home Affairs to liaise with Australian and NSW Anti-Slavery Commissioners regarding lessons learned from the review
3. Minister for Home Affairs to implement pre-departure briefings for Subclass 407 training visa holders consistent with Recommendation 46 of the Hidden in Plain Sight report (December 2017)
4. Australian Anti-Slavery Commissioner and NSW Anti-Slavery Commissioner to liaise and work collaboratively with Commonwealth agencies to improve reporting of modern slavery offences, including considering development of a national modern slavery hotline
5. Commissioner of NSW Police Force to liaise with NSW Anti-Slavery Commissioner regarding development and implementation of mandatory modern slavery training for officers in high-risk areas (regional/rural/agricultural areas)
6. Coronial brief of evidence and transcript to be referred to Australian Federal Police for consideration as to further investigations