Coronial
VICother

Finding into death of Dalvir Singh

Deceased

Dalvir Singh

Demographics

27y, male

Date of death

2014-02-13

Finding date

2015-03-26

Cause of death

hanging

AI-generated summary

Dalvir Singh, a 27-year-old Indian national, died by hanging in immigration detention on 13 February 2014. He had attempted suicide in police custody 16 days earlier but this critical information failed to reach detention centre staff due to inter-agency communication breakdown. Victoria Police did not document his previous suicide attempt on the transfer form, and conflicting evidence exists about verbal notification to Serco officers. The AFP later sent information about his suicide risk but DIBP did not action it. IHMS (health providers) conducted mental health assessments based on his self-report without knowing his history. The coroner found no single factor caused his death but identified systemic failures in information sharing between agencies. Multiple procedural improvements have since been implemented including revised forms, enhanced communication protocols, and database system upgrades.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

psychiatrygeneral practiceemergency medicine

Error types

communicationsystem

Drugs involved

buprenorphine/naloxoneheroin

Clinical conditions

opioid dependencedepressionsuicide riskfamily violence perpetrator

Contributing factors

  • inter-agency communication failure regarding previous suicide attempt
  • loss of liberty
  • breakdown in relationships with wife and son
  • potential criminal and civil consequences of family violence behaviour
  • risk of deportation
  • opiate withdrawal
  • separation from family and community supports
  • uncertainty about future
  • previous suicide attempt in custody not communicated to detention centre staff
  • AFP warning email about suicide risk not actioned by DIBP

Coroner's recommendations

  1. Department of Immigration and Border Protection, Serco and Victoria Police meet to develop coordinated transfer of custody process ensuring all relevant information is conveyed contemporaneously with detainee
  2. DIBP, Serco and Victoria Police each independently ensure necessary internal policies and procedures are effectively developed and implemented for custody transfers
  3. DIBP, Serco and Victoria Police each ensure employees are aware and appropriately trained in custody transfer process aspects
  4. Serco and DIBP collaborate to amend Self Harm Assessment Interview to specifically question all detainees about mental health and suicide/self-harm history and ensure information is appropriately actioned
  5. DIBP, Serco and IHMS meet to consider feasibility of developing system whereby qualified mental health practitioners observe and interact with detainees in common areas, particularly during high-risk periods such as first detention, deportation notification, or when identified as at-risk
Full text
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Source and disclaimer

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