Villawoodfindings redacted

Contributing factors

• Failure to follow SASH (Suicide and Self Harm) protocols
• Inadequate mental health risk assessment and monitoring
• Poor communication and information sharing between DIAC, Serco, and IHMS
• Systemic failures in case management
• Inadequate staff training in suicide prevention and crisis de-escalation
• Misdiagnosis and ineffective psychiatric treatment (Al-Akabi)
• Failure to escalate concerns and act on detainee requests
• Precipitous use of force decision without negotiation (Rauluni)
• Failure to maintain security observations (Saunders)
• Psychological impact of detention, separation from family, and fear of return to country of origin
• Lack of coordination between agencies regarding use of force authorization

Coroner's recommendations

1. Revise the Serco Contract and Procedures Advice Manual (PAM 3 – Removals from Australia) to clarify procedures and authority for aborting a removal when a detainee is resisting and threatening self-harm or suicide
2. Revise DIAC use of force policies to provide guidance on matters to be considered when authorizing use of force
3. Amend the Detention Services Manual to prohibit notification of negative decisions including removals on Thursday or Friday
4. Direct DIAC Case Managers to make referrals for risk assessments to IHMS as soon as risk factors become apparent
5. Implement a policy requiring all risk assessment referrals to IHMS be made in writing, with periodic follow-up and documented results recorded in Portal
6. Direct DIAC staff to make contemporaneous notes in Portal regarding dealings with detainees, specifically recording observations of risk factors and information received from other agencies
7. Implement a procedure whereby DIAC Case Managers must seek all available information when risk of self-harm or suicide is suspected and obtain corroborative information
8. Develop Serco procedures for proactively seeking information on risk assessment outcomes and documenting risk factors and assessment results in detainee files
9. Ensure Serco communicates the need for additional vigilance to all officers in relevant compounds
10. Develop a Serco policy on use of force authority, including risk assessment, appropriate planning, and de-escalation techniques
11. Develop IHMS standard procedure for suicide and self-harm risk assessment with clear guidance on topics, assessment tools, corroborative information, and documentation requirements
12. Implement periodic training for IHMS mental health staff on risk assessment procedures and minimum documentation requirements
13. Require IHMS to notify DIAC and Serco in writing of the outcomes of risk assessments
14. Develop joint policy guidance (DIAC, Serco, IHMS) on what mental health information IHMS can provide to DIAC and Serco on a 'need to know' basis without consulting Detention Health Services
15. Develop a policy (DIAC and Serco, with NSW Police and Federal Police) permitting timely police assistance including trained negotiators for high-risk situations
16. Consider changing the clinical governance structure at VIDC so that mental health services are overseen by a consultant psychiatrist