Deceased
Dalvir Singh
Demographics
27y, male
Coroner
Coroner Jacqui Hawkins
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 — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Court Reference: 2014 / 0867
Form 37 Rule 60(1) Section 67 of the Coroners Act 2008 -
Inquest into the death of Dalvir Singh
Delivered On: 26 Match 2015 Delivered At: Coroners Court of Victoria Hearing Dates: 28 October 2014; and
19-28 November 2014 Findings of: Coroner Jacqui Hawkins
Representation: Mr G Barnes appeared on behalf of Ms Bala
Ms C Harris appeared on behalf International Health and Medical Services
Mr P Lawrie appeared on behalf of the Chief Commissioner of Police
Mr P Rozen appeared on behalf of Serco Australia Pty Ltd
Mr T Wraight appeared on behalf of the Department of Immigration and Border Protection
Counsel Assisting the Coroner Mr S McGregor of counsel
Ms § Melntyre, solicitor of the Coroners Court of Victoria
I, Jacqui Hawkins, Coroner having investigated the death of Dalvir Singh AND having held an inquest in relation to this death on 28 October 2014 and 19-28 November
2014
at MELBOURNE
find that the identity of the deceased was Dalvir Singh born on 15 October 1986
and the death occurred on 13 February 2014
at the Maribyrnong Immigration Detention Centre, 53 Hampstead Road, Maribyrnong, Victoria,
3032
from:
1 (a) HANGING
in the following circumstances:
Dalvir Singh was a 27 year old Indian Citizen who was in custody at the Maribyrnong Immigration Detention Centre (MIDC) at the time of his death. At approximately 6.35pm on 13 February 2014, he was located deceased in his bedroom at the MIDC where he had taken his own life by hanging.
On 1 October 2007, Mr Singh came to Australia on a ‘Higher Education Sector’ Student Visa which was extended for two years. Mr Singh initially resided with his older brother Harpal Singh and he had intended to study hospitality, however this did not eventuate and he gained employment driving taxis, tracks and working on farms.
On 22 October 2009, Mr Singh’s student visa was cancelled and the following day he was classified as an unlawful non-citizen. On 12 November 2009, Mr Singh was granted a bridging visa to regularise his immigration status pending departure from Australia. This bridging visa was valid until 19 November 2009, however Mr Singh did not make any further visa arrangements and he was once again classified an unlawful non-citizen.
Mr Singh met Ms Bala in 2012 and shortly afterwards they commenced an intimate relationship and had a son together in March 2013. Mr Singh and Ms Bala married in June 2013.
5,
Mr Singh had a history of excessive alcohol consumption and had been a heroin user. He had been prescribed Suboxone! by Dr John Sherman since September 2012 however ncither
his wife nor his brother were aware of this information.
Contact with Victoria Police
On 26 December 2013, Victoria Police spoke with Mr Singh in relation to a report of family violence and issued him with a family violence safety notice. At this time, Ms Bala mentioned to police that Mr Singh may have overstayed his visa?
The following day Ms Bala made a further report of family violence and Mr Singh was taken into custedy by Victoria Police and held in a cell at the Pakenham Police Station. He was recorded as having a blood alcohol reading of 0.137%. In custody overnight, Mr Singh attempted suicide by hanging and was taken to Cascy Hospital? and discharged the following morning. The details of this incident were entered into the Law Enforcement Assistance Program (LEAP) and Mr Singh was allocated a self harm warning flag.
On 31 December 2013, an Interim Intervention Order was made. After this time Mr Singh — continued to contact Ms Bala and was notified of allegations that he was in breach. On 10 January 2014, Mr Singh voluntarily attended the Pakenham Police Station where he was
arrested and interviewed.
Involvement with the Department of Immigration and Border Protection
li.
While Mr Singh was in custody at the Pakenham Police Station on 10 January 2014, Victoria Police made enquiries with the Department of Immigration and Border Protection (DIBP) who advised that according to their records Mr Singh was an unlawful non-citizen.
Mr Luke Cooper, Compliance Officer for DIBP emailed Victoria Police and requested that they detain Mr Singh pursuant to section 189 of the Migration Act 1958 (Cth) (Migration Act) and attached two forms for completion."
Constable Sheree Osborne completed the DIBP Form 1275 which required Mr Singh’s personal particulars as well as other relevant information, including any health issues. Once
completed, Sergeant Richard Dawson returned the form to Mr Cooper by email.
“Suboxone contains buprenorphine hydrochloride and naloxone hydrochloride. Buprenorphine acts as a substitute for opiate drugs like heroin, morphine or oxycodone and it helps withdrawal from opiate drugs over a period of time, When taken sublingually (under the tongue) as prescribed, naloxone has no effect, as it is very poorly absorbed. However, if SUBOXONE SUBLINGUAL FILM is injected, naloxone will act to block the effects of other opiates like heroin, morphine and oxycodone, leading to bad withdrawal symptoms.” Suboxone Consumer Medicine Information Sheet.
Exhibit 90 — Balance of Inquest Brief, Statement of Ms Bala dated 28 March 2014, Inquest Brief at p44
Part of Monash Health
Exhibit 2 — Request for Officer to Hold in Immigration Detention form, Inquest Bricf at p1324; Exhibit 3 — Form 1275 — Police Record of Immigration Detention, Inquest Brief at p1325
13,
Mr Cooper then conducted a Compliance Clicnt Interview (CCI) with Mr Singh by telephone” and determined that he posed a risk to the migration process and should be detained.
Mr Cooper then issued a Transfer of Custody form® which authorised Victoria Police to transfer custody of Mr Singh to Serco Australia Pty Limited (Serco). He also sent a Request for Service (RFS) to Serco and Serco Client Services Officers (CSOs) Mr Barnsley and Mr Harris were tasked with transferring Mr Singh from the Pakenham Police Station to the
There is conflicting evidence as to whether Victoria Police members notified either of the Serco officers that Mr Singh had previously attempted suicide whilst in custody.
Immigration Detention
15,
19,
At the time of Mr Singh’s death there were approximately 95 detainees at the MIDC which has an operating capacity of 99 detainees.®
When Mr Singh arrived at the MIDC on 10 January 2014, CSO Ms Matcta Zyntek, conducted his induction including a Self Harm Assessment Interview.’ The following day a ‘Mental Health Assessment was conducted by Ms Amy Hubbard, Registered Nurse who was employed by International Health and Medical Services (HMS). Mr Singh did not disclose any mental health issues during either interview nor did he disclose any previous self harm or suicide attempts. ,
On 11 January 2014, Mr Singh was further assessed by Nurse Hubbard in relation to his opiate withdrawal and Suboxone prescription. Nurse Hubbard made concerted efforts to ensure that Mr Singh could access his Suboxone medication which he thereafter took daily whilst detained at the MIDC.
On 12 January 2014, Serco created a Individual Management Plan (IMP) which documented amongst other things information about his previous drug use.
On 13 January 2014, DIBP Security Liaison Officer Daniel Schmidts emailed Victoria Police seeking information that might assist management of Mr Singh while in detention, including a request for details of any pending criminal charges.
On 14 January 2014, Julie Gambrell from DIBP was assigned as Mr Singh’s Case Manager, She engaged in a general discussion with Mr Singh about his background information.
The Australian Federal Police (AFP) assisted the MIDC with checking Mr Singh’s identity via the National Automated Fingerprint Identification System (NAFIS).
© we MA
Exhibit 4 — Client Compliance Interview by Luke Cooper dated 10 January 2014, Inquest Brief at p1327.
Exhibit 5 — Transfer of Custody Form dated 10 January 2014, Inquest Brief at p1327
Exhibit 16 — Statement of Peter Barnsley dated 10 October 2014, Inquest Brief at p1934
Exhibit 81 — Statement of Johnathon Holmes dated 15 July 2014, Inquest Brief at p246
Exhibit 32 — Serco Self Harm Assessment Interview Inquest Brief at pp537-538
23,
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On 21 January 2014 AFP notified DIBP by email of warnings in relation to Mr Singh’s criminal history of “family violence/assault” and “suicide/self-harm” in the Victorian jurisdiction, No action was taken in response to this email.
On 24 January 2014, a comprehensive Mental State Examination was conducted by Registered Psychiatric Nurse Jan Garlick which included completion of the Depression, Anxiety and Stress Scale (DASS21) and a General Health Questionnaire (GHQ30)."" No concern for Mr Singh’s mental health arose from this.
By 13 February 2014, DIBP had tentatively set a date in late February for Mr Singh’s removal however Mr Singh is not believed to have been informed of this. u Between 6.15pm and 6.26pm on this day, closed circuit television (CCTV) footage shows Mr Singh entering and exiting his room a number of times. At 6.26pm, Mr Singh opened the door to his room, looked into the corridor and then closed the door again.
Serco CSO Mark Mayne conducted a routine welfare check at approximately 7.05pm. When he did not receive a response to a knock on Mr Singh’s door he entered the room and found Mr Singh tied by his neck to the railing on his bed. Mr Mayne called for urgent assistance.
Additional Serco officers arrived and assisted Mr Mayne with cardiopulmonary resuscitation (CPR). Medical staff from IHMS arrived and assisted until the paramedics were present who then assumed responsibility for the CPR. Resuscitation attempts were ultimately unsuccessful and Mr Singh was pronounced deceased at 7.21pm.
Mr Singh spent a total of 34 days in detention at the MIDC. According to Mr Daniel Florent, Director of Detention Operations at DIBP, Mr Singh interacted well with other detainees, participated in programmes and activities and presented with little or no indication of stress or anxiety. Further, his time in detention
was free of incidents and consequently he was not placed on an increased level of the Psychological Support Program or a Behaviour Management Plan.
The Coroners Court of Victoria is an inquisitorial jurisdiction." The role of the coroner in this State includes the independent investigations of deaths to contribute to a reduction in the number of preventable deaths, the promotion of public health and safety, and the administration of justice. It is not the role of the coroner to lay or apportion blame, but to
establish facts. 4
Exhibit 52 — Mental State Examination Assessment dated 24 January 2014, Inquest Brief at p1592; Exhibit 49 — Statement of Ian Garlick dated 13 October 2014, Inquest Brief, p1540
Exhibit 79 — Statement of Daniel Florent dated 14 July 2014, Inquest Brief, at p1048
Exhibit 79 — Statement of Daniel Florent dated 14 July 2014, Inquest Brief, at p1050
Section 89(4) of the Coroners Act
Keown v Kahn (1999) 1 VR 69.
A coroner may comment on any matter connected with the death, may report to the Attorney-General and may make recommendations to any Minister, public statutory authority or entity, on any matter connected with the death, including recommendations relating to public health and safety and the administration of justice.
As Mr Singh’s death occurred while in the custody of the DIBP an inquest into his death was mandatory.'°
In writing this finding I have considered the Charter of Human Rights and Responsibilities Act 2006 (Vic), particularly in the context of how it relates to investigations into the conduct of public authorities, especially when people die while in the care of public authorities, for
example, deaths in custody.”
Mr Singh‘s death was subject to a thorough coronial investigation in which extensive further material was requested from and provided by the following Interested Parties: « Ms Bala e Chief Commissioner of Police e Serco e IHMS e DIBP © Monash Health.'® .
‘Two directions hearings were held on 16 July 2014 and 23 September 2014 to assist in defining the direction and scope of my investigation.
35, An inquest into the death of Mr Singh commenced on 28 October 2014 and resumed between 19 and 28 November 2014. To assist with my understanding of the circumstances of Mr Singh’s death, a viewing of the MIDC facility was conducted on 19 November 2014.
Witnesses
© Mr Luke Cooper, Compliance Officer, DIBP
e Mr Peter Barnsley, Client Services Officer, Serco
© Mr Moomooga Harris, Client Services Officer, Serco e First Constable Sheree Osbome, Victoria Police
e Sergeant Richard Dawson, Victoria Police
Section 72(1) and (2) of the Coroners Act
See sections 4 and 52(2)(b) of the Coroners Act 2008 and Regulation 7 of the Coroners Regulations 2009.
Section 9 and 22 of the Charter of Human Rights and Responsibilities Act 2006 (Vic)
Tnote that Monash Health were excused at the second directions hearing held on 23 September 2014 from participating further in the Inquest process, as an asscssment of the appropriateness of their involvement with Mr Singh was considered outside scope.
e Ms Anne Chiang, Client Services Officer, Serco
e Ms Amy Hubbard, Registered Nurse, IHMS
e Dr Emily Shaw, General Practitioner, THMS
e Mr Ian Garlick, Registered Nurse, IHMS
© Dr Mark Parrish, Regional Medical Director, THMS
® Superintendent Andrew Humberstone, Victoria Police
e Mr Daniel Schmidts, Security Liaison Officer, DIBP
e Ms Julie Gambrell, Senior Case Manager, DIBP
e Mr Michael Kingma, Contre Manager, MIDC, DIBP
e Mr Daniel Florent, Director, Detention Operations, DIBP
¢ Mr Johnathon Holmes, National Operations Manager, Serco e Dr John Sherman, General Practitioner, Open Family Footscray.
At the conclusion of the evidence, I considered whether an independent expert would assist my understanding of the self-harm and suicide risk screening processes and the mental health monitoring and management of Mr Singh. Based upon all of the evidence, I concluded that this was unnecessary.
Written submissions and submissions in reply were provided by each Interested Party in February 2015.
Issues investigated
Section 67 of the Coroners Act requires me to find if possible the identity of the deceased,
the cause of death and the circumstances in which death occurred.
On 14 February 2014, Dr Jacqueline Lee, Forensic Pathologist at the Victorian Institute of Forensic Medicine conducted an autopsy on the body of Mr Singh and attributed his medical cause of death as 1a) HANGING.””
No drugs or alcoho! were detected in his blood as part of the toxicological analysis.
A statement of identity was completed by Anne Chiang dated 13 February 2014.
Exhibit 13 — Autopsy and Toxicology Report, signed by Dr Jacqueline Lee, Forensic Pathologist dated 6 June 2014.
Intention to suicide
43,
44,
45,
The weight of the evidence available to me prior to the commencement of the Inquest established that Mr Singh’s death was a suicide. Suicide has been defined as: voluntarily doing an act for the purposes of destroying one's life while one is conscious of what one is doing. In order to arrive at a verdict of suicide there must be evidence that the deceased intended the consequence of his act.”!
Evidence in support of this finding included Mr Singh’s previous suicide attempt in custody, the CCTV footage which excluded the possibility of another person’s involvement and the explicit and implicit expressions of suicidal intention contained in notes located at the
scene.”
It is not possible to nominate with any degree of certainty the contribution of any one reason for a person’s decision to take their own life. Nevertheless, it is evident that a number of stressors were operant at the time of Mr Singh’s death that placed him in a particularly
vulnerable position including:
e The loss of his liberty;
e The breakdown in his relationships with his wife and son;
e Potential civil and criminal consequences of his family violence behaviour;
e The possibility of deportation;
e Withdrawal from opiates;
° Separation from family, friends and other community supports; and
e General uncertainty about his future.
T accept that Mr Singh was not showing any significant overt signs that he was particularly distressed or experiencing suicidal ideation in the days leading up to his death. Further, I agree that, as opined by Nurse Garlick, this would indicate his action on the day of his death
“may have been impulsive”.
However, although Mr Singh’s intent was not in issue at Inquest, given the known vulnerability created by the accumulation of the above stressors, his decision to take his life raises questions about whether the agencies involved in the management of his immigration
detention appropriately identified, treated and monitored his mental state.
Issues investigated as part of the Inquest
A number of complex and interrelated issues pertaining to the circumstances of Mr Singh’s death were identified throughout the course of my investigation, however the following are
canvassed at length in this Finding:
Rv Cardiff City Coroner, Ex parte Thomas [1970] 1 WLR 1475.
Exhibit 90 — Balance of Inquest Brief, Inquest Brief at pp 58-60 Transcript of evidence, p483
49,
e Inter-agency communication about Mr Singh's previous suicide attempt;
These issues are explored in relation to each of the following in turn:
® Serco;
e THMS; and
e DIBP.
I do not propose to recount or summarise all of the evidence but rather refer to the parts that are necessary, touching upon the relevant circumstances investigated as part of the inquest.
54,
The appropriateness of the response by Victoria Police and Casey Hospital to Mr Singh’s previous suicide attempt did not fall within the scope of the Inquest. In contrast, who did or did not have knowledge of the circumstances was germane to my investigation because of the question’s relevance to subsequent assessments and management. This information about Mr Singh’s previous suicide attempt was important and should have been exchanged
between the agencies was not disputed by any of the Interested Parties at Inquest.
When Mr Singh attended Pakenham Police Station on 10 January 2014, Constable Osborne was aware of the LEAP warning flag regarding Mr Singh and his previous suicide attempt.”4 Sergeant Dawson stated that Constable Osborne informed him of this information’? and he instructed her to ensure that Constable Raven maintained observations on Mr Singh while further enquiries with DIBP were made,”® It is clear that key members of Victoria Police were aware of his history and the implications of this for his ongoing management.
While Victoria Police members are regularly involved in transferring people between police stations and custody centres, the transfer of Commonwealth immigration detainees is far less common, Indeed, prior to their involvement with Mr Singh, neither Constable Osborne nor
Sergeant Dawson had ever experienced a transfer of custody to DIBP or Serco.””
It is problematic that Victoria Police did not have any documented procedures in the Victoria Police Manual (VPM) or provide any training to guide Sergeant Dawson and Constable Osborne on the requirements and best practice for the transfer of Mr Singh’s custody. Consequently, the police members were reliant upon DIBP’s instructions and otherwise applying the general transfer of custody principles to this novel exercise.
A number of issues arose with respect to sharing pertinent information including:
e Transfer of information to DIBP
m4
Exhibit 22 — Statement of Constable Sheree Osborne dated 29 April 2014, Inquest Brief at p937 Exhibit 29 — First statement of Sergeant Richard Dawson dated 31 July 2014, Inquest Brief at p940 Exhibit 22 — Statement of Constable Sheree Osborne dated 29 April 2014, Inquest Brief at p938 Transcript of evidence, p267
e ‘Transfer of information to Serco e Ability to share information on internal databases.
In addition I address in short compass the issue raised by counsel for Ms Bala in relation to Victoria Police’s response to allegations that Mr Singh continucd to breach the FVIO.
Transfer of information from Victoria Police to DIBP
60,
When Mr Cooper requested Victoria Police to detain Mr Singh he required them to complete a Form 1275, which was done by Constable Osborne. Although asked at Question 11 of this form the:
Reason/circumstances for detention and any relevant information including travel documents, health issues, injuries, etc.
Constable Osborne did not make reference to Mr Singh’s previous suicide attempt anywhere on the Form 1275 and noted “Nil health issues disclosed”.”*
Constable Osborne gave evidence that she did not record information about Mr Singh’s previous suicide attempt because the question asked her to comment about Aeulth as opposed to mental health issues. She considered. health issues were “medical such as heart conditions or diabetes” and Mr Singh had not indicated any such health problems to her.
When asked specifically whether a suicide attempt was a health issue Constable Osborne said no” because in her mind medical conditions and mental health are quite separate things.*”
Constable Osborne stated that at the time she did not appreciate that Question 11 was asking for information contained in Mr Singh’s LEAP record,*! and she believed that the form related mainly to custody issues not health issues. Constable Osborne indicated that if Question 11 included an information request about health, welfare and behavioural issues,
she would have included the suicide risk.*
The evidence is that Sergeant Dawson had an opportunity to review the completed Form 1275 before returning it to Mr Cooper however he could not remember whether he had.*?
With the knowledge he has now, he accepts that the warning regarding the suicide risk
should have been included in answer to Question 11 because he recognised its relevance.**
Mr Cooper’s evidence was that DIBP provide police with an opportunity to make known any concerns on the Form 1275 and during conversations when they ask how the person was
Exhibit 3 — Form 1275 — Police Record of Immigration Detention, p1325 Transcript of evidence, p206 Transcript of evidence, p209 Transcript of evidence, p206 Transcript of evidence, p207 Transcript of evidence, p265 Transcript of evidence, p258
64,
located and then referred to them. Although conceding that he ought to have raised Mr Singh’s previous suicide attempt with Mr Cooper on the phone,** Sergeant Dawson could not recall whether he did so.*°
Mr Singh’s previous suicide attempt was never communicated to Mr Cooper, either by telephone or in writing on the Form 1275. The underlying reason for this seems to have been a misunderstanding on the part, of Constable Osborne and Sergeant Dawson about the purpose and use of Form 1275. Specifically, they construed the purpose of the document more narrowly than it was intended.
Counsel for DIBP informed the Inquest that their client had since revised Form 1275 and the email to which it is attached to rectify any obscurity in relation to the information required.
The Revised Form 1275 came into operation in November 2014.*’ It contains an additional question which specifically asks: “Is there a record of any health/mental health or behavioural issues recorded on police systems or other relevant data sources”. Constable Osborne indicated that she would sec this new question as an appropriate place to mention self-harm risks.** Sergeant Dawson agreed that the Revised Form 1275 was a significant improvement’ and in his opinion would elicit appropriate checks of Victoria Police LEAP records and prompts the communication of information such as the risk of suicide or selfharm.”
In addition, submissions on behalf of the Chief Commissioner of Police confirmed that the role and importance of the Revised Form 1275 will be supported by new instructions in the
Victoria Police Manual.*!
Transfer of information from Victoria Police to Serco
There is conflicting evidence as to whether Serco officers Mr Barnsley and Mr Harris were advised by Victoria Police of Mr Singh’s previous suicide attempt while at the Pakenham
Police Station.
The evidence of Sergeant Dawson was that, as Mr Singh was being transferred to the vehicle in the collection bay, he informed the older of the two Serco officers.” At Inquest, Sergeant Dawson testified that although he could not remember the exact conversation, he was of the belief it occurred because “it was in the interests of Mr Singh and also the people looking
Transcript of evidence, p269
Transcript of evidence, p262
Exhibit 15 — Revised Form 1275 in effect as of 18 November 2014
Transcript of evidence, p208
Transcript of evidence, p259
Transcript of evidence, p258
Submissions on behalf of the Chief Commissioner of Police, p9
At Inquest it was established that this was most likely to have been Mr Barnsley.
ic
70,
after him that they should have that information”. Sergeant Dawson was unable to provide any evidence to corroborate his version of events.“* He confirmed in evidence that he did not make a note in his daybook and that in hindsight he probably should have.
In contrast, neither of the Serco officers had any recollection of this information being provided by Sergeant Dawson or any other member of Victoria Police. Mr Barnsley denied that Sergeant Dawson advised him of any previous suicide attempt.’ Had he been provided with this information, he would have asked Mr Harris to note it on the Transport and Escort Operational Order,”” advised the MIDC operations manager and included the information on the Initial Security Risk Assessment Form.*® Mr Barnsley informed the court that his philosophy is “if it isn’t in writing it never happened”.””
Mr Harris supported Mr Barnsley’s version of events. He believes that he was within earshot of Mr Barnsley at all times while at the station and at no time did he hear Sergeant Dawson or any other police officer inform Mr Barnsley of a previous suicide attempt’and if he had, he would have noted it down.
All three witnesses presented as credible and honest however as Counsel for the Chief Commissioner of Police succinctly articulated: “all three witnesses had imperfect memories”,°! Given this and the lack of any objective and contemporaneous evidence, I am ultimately unable to determine on the balance of probabilities whether Sergeant Dawson did convey this information verbally to either of the Serco officers.
What is evident, however, is that it was not formally documented and as a result could not inform subsequent care and management decisions. Sergeant Dawson conceded at Inquest that there had been a degree of informality about the way in which he communicated a matter of gravity to another custody provider.
Although the importance of recording information in writing is not a novel concept to members of Victoria Police, the ultimate breakdown in communication may be understood in light of the fact that the transfer of custody to Serco was an experience out of the ordinary
for members of Victoria Police.
As
Transcript of evidence, p263
Transcript of evidence, p263
‘Transcript of evidence, p266
Transcript of evidence, p167
Transcript of evidence, p136
Exhibit 16 — Statement of Peter Barnsley dated 10 October 2014, Inquest Brief at p1934; Transcript of evidence, plis
Transcript of evidence, p137
Exhibit 21, Statement of Moomooga Harris dated 8 October 2014, Inquest brief at p1931 Submissions on behalf of the Chief Commissioner of Victoria Police, p7
Transcript of evidence, p268
Accordingly, the ability to manage Mr Singh while in immigration detention would have been strengthened by better systems being in place in the early stages of his custody to ensure that essential information was clearly documented and therefore readily conveyed to
other agencies.
Ability of Victoria Police to share internal records with other agencies
The Inquest considered whether Victoria Police could have provided Serco or DIBP with information from internal databases, such as LEAP records. Members of Victoria Police were unsure of whether this was permitted. In fact, Constable Osborne did not believe she was authorised to release LEAP information to another party.”
At the time a Memorandum of Understanding (MOU) existed between DIBP**, AFP and Victoria Police to facilitate the provision of police services to Immigration Detention Facilities in Victoria. Section 9 specifically dealt with Information Exchange and Data Security. Paragraph 9.1 stated:
The Participants may exchange information pursuant to this MOU in accordance with relevant Commonwealth, state and territory laws.*°
Although the MOU clearly provided for the exchange of information with DIBP, Sergeant Dawson and Constable Osborne appear not to have been aware of its existence.’ Sergeant Dawson indicated that he could have provided the Serco officers with a copy of the LEAP printout that evening but was unable to provide a reason for why he had not. 8
I consider that the provision of the LEAP printout would have facilitated the easy exchange of information about Mr Singh’s previous suicide attempt between DIBP, Serco and subsequently, THMS. Although the MOU allows for the exchange of information, it would appear that this did not occur, in part because there were not suitable procedures in place to
promote it.
Breach of the Family Violence Intervention Order (FVIO)
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Counsel for Ms Bala raised concerns about the excessive number of phone calls made to her by Mr Singh whilst in detention. Phone records obtained as part of this investigation provide evidence in support of the allegations that the FVIO had been breached.
1 affirm the importance of providing a response to family violence that promotes the safety of victims and the accountability of perpetrators, however I did not consider that Victoria
Transcript of evidence, p233
Exhibit 90 - Balance of Inquest Brief, Memorandum of Understanding, at p1005
At the time of the execution of the Memorandum of Understanding the DIBP was known as the Department of Immigration and Citizenship (DIAC)
Exhibit 90 — Balance of Inquest Brief, Memorandum of Understanding, at p1011
Transcript of evidence, p215
Transcript of evidence, p266
Police’s response fell within the ambit of my investigation of Mr Singh’s death and I did not call the police officer in charge of investigating them to give evidence. I therefore do not
consider it appropriate to comment on this issue.
Changes made by Victoria Police following the death of Mr Singh
sl.
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In April 2014, Sergeant Pietrosanto reviewed the circumstances of this incident and identified that the VPM gave no guidance concerning the transfer of custody to external
agencies. He recommended that a policy position or amendment was required.”
At the commencement of the Inquest, Superintendent Andrew Humberstone presented an amended VPM Guideline on Safe Management of Persons in Police Care or Custody, highlighting in particular section 9.4 Transfer to External Agency.©
Superintendent Humberstone was cross-examined on the efficacy of the document and the potential to create confusion by adding another document into the process. He agreed that it would be preferable for all relevant agencics to develop and implement a single document.®!
At inquest, | affirmed the importance of a coordinated response to the issue and suggested that DIBP, Serco and Victoria Police meet with this purpose in mind, Victoria Police subsequently communicated to the Court through Counsel that further development or promulgation of the amended guidelines would be suspended pending consultation with DIBP and Serco.”
Serco has responsibility for the management and control of Australian immigration detention centres including the MIDC. Whilst DIBP owns the MIDC, it grants Serco a licence to occupy and use the premises and contracts Serco to provide “a range of services to promote the wellbeing of people in detention and create an environment that supports security and safety”,
The process for physical detention of Mr Singh on behalf of the DIBP occurred pursuant to the RFS sent by Luke Cooper on 10 January 2014 to Serco,
Although Serco does not receive a copy of the Form 1275 completed by Victoria Police, the RFS is required to contain all relevant personal information provided on that form. Mr Holmes stated that a detainee’s history of self-harm or suicide attempts is relevant.to Serco and should be included in the RFS.“ In relation to Mr Singh, the RFS specifically noted that there were “no known behavioural/violence concerns. Detainee is taking daily
Exhibit 90 - Balance of Inquest Brief at p968
Exhibit 64 - VPM Guideline on Safe Management of Persons in Police Care or Custody Transcript of evidence, pS80
Submissions on behalf of Chief Commissioner of Police, p&
Exhibit 90 — Balance of inquest brief, Detention Services Contract, Inquest bricf at p2836 Exhibit 81 - Statement of Johnathon Holmes dated 15 July 2014, Inquest Brief at p247
medication for Suboxone for previous drug addiction”. Mr Singh’s level of risk was
recorded as ‘low’.
The risk level indicated in the RFS determines the number of officers required to conduct the task of transfer and as Mr Singh’s risk level was low two officers were assigned, being Mr Barnsley and Mr Harris.
Mr Barnsley had approximately 15 years experience working as a CSO® and Mr Harris four years.®’ As the more senior and experienced CSO, Mr Barnsley was the ‘officer in charge’ of the transfer.
Before leaving the MIDC, Mr Barnslcy and Mr Harris were provided equipment, a briefing and a Transport and Escort Operational Order form which provides details of the pick up location, detainees risk rating and other relevant information. Mr Barnsley said his usual practice was to review this form prior to departing. Detainees were usually transported to he MIDC from the airport, but other than the location, Mr Singh’s was just a routine
transfer,
Although Serco and IHMS work collaboratively to manage the physical and mental wellbeing of detainees,” it is to the following aspects of management by Serco employces that I now turn my mind:
e Initial security risk assessment;
e Self-harm assessment interview;
e Individual Management Plan and Personal Officers; and
e Alleged breach of the FVIO.
Initial Security Risk Assessment
In accordance with Serco policy, Mr Harris observed Mr Singh en route to the MIDC and completed an MIDC Initial Security Risk Assessment’! form on arrival, which he subsequently provided to Serco’s client services department. In evidence, Mr Barnsley explained that this risk asscssment relates more to security risk than detainee safety; for example the risk of escape or violence during transportation.”
Although Mr Singh was noted to be calm and compliant throughout the trip, Mr Barnsley indicated that Mr Singh’s previous suicide attempt, if known, would have required him to have been rated as ‘high’ on the Initial Security Risk Assessment Form. However, on the
oO aA pn
Exhibit 17 -- Request for Service document signed 10 January 2014, Inquest brief at p528 Exhibit 16 — Statement of Peter Barnsley dated 10 October 2014, Inquest bricf at p1933 Exhibit 21 — Statement of Moomooga Harris dated 8 October 2014, Inquest brief at p1929 Exhibit 16 ~ Statement of Peter Barnsley dated 10 October 2014, Inquest brief, p1933 Transcript of evidence, p128
Exhibit 81 - Statement of Johnathon Holmes dated 15 July 2014, Inquest Brief at 246 Exhibit 19 - MIDC Initial Security Risk Assessment form dated 10 January 2014, p2027 Transcript of evidence, p121
93,
basis that they had no information to the contrary, a consensus was reached to rate Mr Singh as low.”
It is therefore clear that the flow-on effect of the breakdown in communication from Victoria Police to Serco and DIBP was that subsequent risk assessments were based on an incomplete picture. I therefore reiterate in this context the importance of interagency
communication and collaboration.
Self Harm Assessment Interview
On arrival at MIDC, detainees undergo an administrative induction process including photographing, fingerprinting and the recording of information such as personal characteristics and property in their possession. The detaince is shown an induction video, provided with fresh clothes and information about their rights and responsibilitics. They are also given the opportunity to make a phone call.
As part of this process they also complete a Self Harm Assessment Interview which comprises scripted questions as outlined in the DIBP Detention Services Manual (DSM).
When Mr Singh arrived at the MIDC, CSO Mateta Zyntek inducted Mr Singh and
conducted his Self Harm Assessment Interview,”
Conduct of the interview
Mr Singh’s response to Question 5 of the interview (“Tell me how you’te felling now?”), was recorded as “Feeling not well”.”° Ms Zyntek testificd that she did not pursue an explanation from him because he started to cry and indicated that he wanted to talk to his wife.”’ She noted that this response was not unusual and many people who come to the detention centre are not happy to be there, a lot of people cry, are stressed, depressed and scared.”* Ms Zyntek further testified that she did not consider that Mr Singh was particularly
upset nor was he displaying any concerning behaviour.”
Mr Singh responded affirmatively in response to Question 6 (“Do you feel in control of your emotions now?). The consequence of this was that Ms Zyntek was directed by the form to skip the follow-up question which related to whether Mr Singh was having any thoughts of hurting or harming himself.*°
ia qW WR vid
Exhibit 16 - Statement of Peter Barnsley dated 10 October 2014, Inquest Brief at pp1931 and 1933A Submissions on behalf of Serco, p10
Exhibit 32 — Serco Self Harm Assessment Interview, Inquest Brief at p1923
Exhibit 32 -- Serco Self Harm Assessment Interview, Inquest Brief at p1925
Transcript of evidence, p293
Transcript of evidence, p361
Exhibit 31 — Statement of Mateta Zyntck dated 18 September 2014, Inquest Brief at p1916; Transcript of evidence, p361
Exhibit 31 — Statement of Mateta Zyntek dated 18 September 2014, Inquest Brief at p1916
The submissions on behalf Ms Bala indicated that the Sclf Harm Assessment Interview form should be amended and enhanced.*' Ms Zyntek indicated at Inquest that since the death of Mr Singh she always asks detainees if they have thoughts about hurting or harming themselves even if they feel in control or their emotions.” I consider that asking this, as a separate and independent question, is an appropriate adjustment to the interview process.
Recording of information on the Self Harm Assessment Interview form
99,
The level of information recorded on the Self Harm Assessment and Interview Form was inadequate. Many questions contained answers of only a few words and Ms Zyntek’s exchange with Mr Singh raised a number of aspects of his mental state and wellbeing that could have been the subject of further exploration and record.
Lacknowledge the purpose of the interview as a screening process, yet I note that Ms Zyntek is not medically trained®? however | am of the view that this increases the need to thoroughly document all information provided and observations made. This provides important context to subsequent mental health assessments.
Ms Zyntek herself acknowledged that she could and should have put more information in the document so the next person would be better informed about Mr Singh.“ Serco also accepted that as much detail as possible should be included in the records of Self Harm
Assessment Interviews.®°
Action taken by Ms Zyntek on the basis of the Self Harm Assessment Interview form
On the basis of the Self Harm Assessment Interview and the information provided on the RFS, Ms Zyntek rated Mr Singh as a low risk of self harm and referred him for an initial medical assessment by IHMS the following morning.
KeepSAFE and PSP set out the clinically recommended approach for the identification and support of detainees who have psychological vulnerabilities or are at risk of self-harm and/or suicide. According to Mr Holmes, KeepSAFE and PSP are based upon nine principles of prevention and management of self-harm and includes a detailed SAFE
(Support, Action, Follow up and Evaluation) process, and monitoring and engagement
processes.®°
The KeepSAFE process is triggered when a risk or concern is identified by either Serco or IHMS and/or when information is received from DIBP regarding historical psychological health concerns. If DIBP receives information regarding a history of self harm or suicide
Submissions on behalf of Ms Bala, p33
Transcript of evidence, p362
Exhibit 31 — Statement of Mateta Zyntek dated 18 September 2014, Inquest Brief at p1917 Transcript of evidence, p294
Submissions on behalf of Serco, p11
Exhibit 81 - Statement of Johnathon Holmes dated 15 July 2014, Inquest Brief at p249
attempts, the detainee is assessed as high risk upon induction until the detainee is medically assessed by THMS and a revised risk rating is assigned,®”
In accordance with KeepSAFR, a Serco staff member will either stay with the detainee if high risk until he/she can be assessed by THMS or check on the detainee periodically if moderate or ongoing.®®
Tt was Ms Zyntek’s opinion that there were no factors in relation to Mr Singh that warranted.
consideration of the KeepSAFE process.” The evidence of Ms Zyntek was that, like other CSOs, she relics heavily on the self-disclosure of the detainee. Mr Singh did not disclose any previous scelf-harming behaviour or suicide attempt. Based on this, she did not consider
him to warrant any immediate assistance.
However, submissions for Ms Bala referred to Chapter 6 of the Detention Services Manual” which states that “staff conducting [Self Harm Risk Assessment Interviews] should carefully
»?l and that if a person is showing signs of distress then
observe the person’s level of distress they should be referred to a health professional. On this basis, Mr Singh’s presentation during his interview meant that he ought to have been referred to IHMS for assessment on
the evening of his arrival to the MIDC.”
It is difficult to determine in retrospect whether Mr Singh’s level of distress was such as to warrant an immediate mental health review or monitoring by way of the KeepSAFE program. However, I consider that Ms Zyntek’s understanding of Mr Singh’s mental state may have been different had she been fully appraised of his history of suicide attempts in custody. Indeed, Ms Zyntelk stated that had she known about the previous suicide attempt, she would have placed Mr Singh on KeepSAFE overnight, contacted IHMS on call and
reported it to her supervisor.”
Appropriateness of Serco employees conducting the Self Harm Assessment Interview
The submissions on behalf of Ms Bala suggested that Serco employees should not conduct the Self Harm Assessment Interviews because they are not mental health professionals.”
However, it is clear to me that this preliminary assessment is not intended to be all encompassing. Rather, it serves as a screening mechanism to identify any emergent issues so
Exhibit 81 - Statement of Johnathon Holmes dated 15 uly 2014, Inquest Brief at p249 Exhibit 81 - Statement of Johnathon Holmes dated 15 July 2014, Inquest Brief at p249
Exhibit 34 -. Statement of Mateta Zyntek dated 18 September 2014, Inquest Brief at p1917
Exhibit 66 — Chapter 6 of the Detention Services Manual — Psychological Support Program, Inquest Brief at pp1064-1119 Submissions on behalf of Ms Bala, p33 Submissions on behalf of Ms Bala, p18 Transcript of evidence, p362 Submissions on bchalf of KB, p33
that detainees receive necessary interim assistance prior to a comprehensive assessment by the medical and mental health professionals employed by IHMS.
Accordingly, I do not consider it neccessary that this assessment be carried out by mental health clinicians, Nevertheless, I do consider that CSOs conducting these assessments require a minimum level of training in mental health first aid and in eliciting information from a detainee, actively observing the detainee for signs of distress and ensuring this
information is appropriately documented.
Individual Management Plan and Personal Officers
112,
114,
116,
According to the DSM and the associated operating procedures, an Individual Management Plan (IMP) is to be completed within 1-2 days of the detainee being brought into custody.
The purpose of an IMP is to obtain background information about the detainee to identify and monitor any underlying issues that might need to be addressed.”
On 12 January 2014, CSO Anne Chiang met with Mr Singh to complete his IMP. Ms Chiang stated that before these meetings she usually obtains and reviews the detainee’s dossier, which contains information provided to/obtained by Serco including the original RFS and the Self Harm Risk Assessment.
According to the Serco Incident Review, Mr Singh participated in the development of his IMP and advised Ms Chiang of his drug addiction for which he had medical support.
Further, the Incident Review noted that Mr Singh had stated he had never tried to self harm.”° Ms Chiang did not remember Mr Singh being upset or displaying any concerning behaviour during the interview.’’ She stated that had this been the case she would have reported it to her manager. Ms Chiang testified that if she had known Mr Singh had made a previous
suicide attempt, she would have recorded it on the IMp.8
At the time of developing Mr Singh’s IMP there had not been any notification to Serco by THMS that he required any particular mental health monitoring as a result of an assessment of his risk of self-harm. I note that Serco staff do not receive a copy of the THMS medical assessment of new detainees and are only informed of the level of risk allocated and whether the PSP has been activated.”
The risk recorded on the IMP was marked “medium” which does not appear to accord with any assessments conducted by Serco or IHMS staff. Ms Chiang’s evidence was that this
Transcript of evidence, p385
Exhibit 81 - Statement of Jonathon Holmes dated 15 July 2014, Inquest Brief at 251; Exhibit 43 - IMP File, plo34
Exhibit 42, Statement of Anne Chiang dated 4 September 2014, Inquest Brief at — Inquest Brief at p1032 ‘Transcript of evidence, p387
Exhibit 42, Statement of Anne Chiang dated 4 September 2014, Inquest Brief at — Inquest Brief at p 1030
rating had already been filled in when she accessed the form.'°° No other witness could shed
any light on this although Mr Holmes confirmed that there was no default to a medium risk
rating,‘
Serco records also reveal that Mr Singh participated in the daily life of the facility including
engaging in sports, attending the gym, interacting with a number of other detainees and had
friends from the community visit him,'”
Management of breach of FVIO
A number of witnesses were asked whether they were aware of Mr Singh’s numerous calls to Ms Bala in breach of the FVIO and what implications that might have had for Mr Singh’s ongoing management. The evidence is that no Serco employee was aware of these calls.
However, I note that because MIDC is administrative detention, not a term of imprisonment, detainees are allowed to have access and usc of phones both landline and mobiles, as long as they do not have the capacity to record or video. Therefore, I consider it reasonable that Serco staff were not aware that the calls were being made and thus did not have the opportunity to consider the implications of these breaches for his ongoing mental health
management.
commensurate with health care available to the Australian community, taking into account the diverse and potentially complex health needs of people in detention. '"
Transcript of evidence, p386
Transcript of evidence, p789
12 Exhibit 80 - Serco Post Incident Review — 17 February 2014, Inquest Brief at p202
103 Exhibit 80 - Serco Post Incident Review — 17 February 2014, Inquest Brief at p203 and Exhibit 81 - Statement of Johnathon Holmes dated 15 July 2014, Inquest Brief at p250
Transcript of evidence, p390
105 Exhibit 90 — Balance of Inquest Brief, Health Services Contract, Inquest Brief at p2082
106 Exhibit 54 — Statement of Dr Mark Parrish dated 4 September 2014, Inquest Brief at p1501
(DeHAG) in relation to community-based health care.'"’ The standard of care expected of THMS is described in the Standards for Health Services in Australian Immigration Detention Centres,'°> Immigration detention centres are accredited to these standards by an
independent body.'”
I now tum my mind to the two key mental health assessments conducted by IHMS during
the time of Mr Singh’s detention, being:
¢ the Mental State Examination (MSE) Screening! undertaken by Nurse Amy Hubbard on 11 January 2014; ,
e¢ the more comprehensive Mental State Examination Assessment conducted by Psychiatric Nurse lan Garlick conducted on 24 January 2014;
I then consider the following aspects in relation to IHMS’ management of Mr Singh:
e Management by general practitioner Dr Shaw;
¢ Knowledge of Mr Singh’s previous suicide attempt;
e® Obtaining collateral information from external agencies; and e = Internal reviews; and
e Changes to IHMS systems and processes.
MSE Screening undertaken by Nurse Hubbard
Nurse Hubbard, who is employed by IHMS and presented as a reliable witness at Inquest, advised the Court that the medical induction includes a basic medical and mental health screening assessment. The purpose of the induction is to record a baseline of mental health!!! and involves questions about past history, whether there has ever been any self
harm or previous suicide attempts, any thoughts of suicide, and physical observations. m2
Nurse Hubbard conducted an MSE on 11 January 2014, the day after Mr Singh arrival.'!
He did not present with any evident symptoms of depression. Nurse Hubbard recalled that
Mr Singh made “very good eye contact, he was happy to discuss other things about his
oll4
medication and he was factual, coherent and cooperative throughout the consultation.
a
In 2007-2008 the Mental Health Sub-Group (MHSG) of the Detention Health Advisory Group (DeHAG) reviewed mental health screening arrangements and found that with the exception of the MSE, the tools used were not the most appropriate for the immigration detention environment. “The process described in the instruction reflects the revised approach recommended by the MHSG and endorsed by the DeHAG on 28 February 2008”. Detention Services Manual Chapt 6 - Mental Health Screening, Inquest Bricf p888
Exhibit 36 - (RACGP) Standards for Health Services in Australian Immigration Detention Centres
Exhibit 54 — Statement of Dr Mark Parrish dated 4 September 2014, Inquest Brief at p1502
Exhibit 47 -- MSE Screening dated 11 January 2014
Exhibit 90 ~ Balance of Inquest Brief, Detention Services Manual Chapter 6 - Mental Health Screening, Inquest Brief at p889
Transcript of evidence, p411
Exhibit 46 — Statement of Amy Hubbard dated 19 August 2014, Inquest Brief at p1470
Transcript of evidence, p428
However, she admitted that he did show some annoyance when he answered questions about his wife,'!°
Nurse Hubbard’s notes were reliant on what Mr Singh reported to her. She acknowledged.
that her MSE was brief and could have provided more information. She attested to the fact that she had never been formally trained or supervised in how to complete an MSE record
however she did say that she has conducted hundreds if not thousands of them,!!*
According to Nurse Hubbard, if Mr Singh had presented with any mental health issues such as past experiences of depression or other mental health problems or if she was made aware by him or by any other means of previous suicide attempts she would have immediately teferred him to the IHMS Mental Health Team for review.
At the conclusion of her assessment, based on what he had told her, Nurse Hubbard did not
consider Mr Singh was at risk of self harm of suicide?
Mental State Examination Assessment undertaken by Nurse Garlick
Psychiatric Nurse, lan Garlick is a very experienced mental health nurse with over 30 years experience and was an impressive witness whose evidence was both reflective and thoughtful.
On 24 January 2014, he conducted the detailed Mental State Examination Assessment which DIBP requires IHMS to undertake. Nurse Garlick made notes of this consultation on the IHMS electronic management system, Chiron including that Mr Singh:
e did not present with any biological features of depression;
e had no significant problems with sleep or appetite;
© was well-groomed and able to care for himself;
e had no thoughts of harming himself or others;
® denied any mood problems or history of depression; and
« did not report any previous suicide attempts.
Nurse Garlick used the DASS21 to assess Mr Singh’s symptoms of depression, anxiety and stress''? and the GHQ30" to assist with the detection and diagnosis of formal psychiatric disorders. '*'
Nurse Garlick indicated that Mr Singh’s mental health risk factors included his past history
of heroin use, disrupted family background, the intervention order, potential criminal
1s 8s
Exhibit 46 — Statement of Amy Hubbard dated 19 August 2014, Inquest Brief at p1470
Transcript of evidence, p409
Exhibit 46 — Statement of Amy Hubbard dated 19 August 2014, Inquest Brief at p1471
Exhibit 51 — IHMS Mental Health Assessment dated 24 January 2014; Exhibit 52 — Mental State Examination Assessment dated 24 January 2014
Exhibit 52 — Mental State Examination Assessment dated 24 January 2014, Inquest Brief at p1592
Exhibit 52 — Mental State Examination Assessment dated 24 January 2014, Inquest Bricf at p1592
Exhibit 49 — Statement of Ian Garlick dated 13 October 2014, Inquest Brief at p1540
charges, deportation and a wife and young baby.” He acknowledged that almost “universally everybody who comes into detention is [..] downcast”'™? but that was not always an indication of depression.
According to Nurse Garlick, “Mr Singh did not exhibit any signs of depression or any other psychiatric illness’ and the results of the DASS21 and GHQ30 were “clinically unremarkable”, ‘4 Importantly, he did not consider Mr Singh to be at any significant risk of self harm or suicide.
Nurse Garlick commented that IHMS personnel are highly dependent on Serco staff to provide observations of the detainees, and immigration detention is a strange environment in that: the mental health team is quite isolated from the detainees as opposed to if you were working in a psychiatric hospital you’d obviously be mingling with clients all day, you’d be observing things, noticing things, that’s not something that’s encouraged in fact its -
discouraged, so you’re waiting on information to present to you rather than sort of observing anything yourself.'*°
Management by general practitioner Dr Shaw
137,
138,
IHMS provide general medical practitioners on site at the MIDC three days a week.
Dr Emily Shaw first conducted a health assessment of Mr Singh on 15 January 2014. Dr Shaw indicated that his physical examination and history indicated that he was an essentially well gentleman who had been referred to her for his Suboxone prescripti on,
Dr Shaw took a history of his drug use and found that he had been using heroin for a period of two weeks and that he had not used any other illicit substances.!?” Dr Shaw prepared a management plan to reduce his Suboxone medication from 8 milligrams to 4 milligrams and to review him at a later date; Mr Singh agreed with this plan. Dr Shaw commented that in her experience people who are on opiate replacement medication are very focussed on
knowing their medication dosage.'””
Dr Shaw said Mr Singh was not agitated or distressed when she saw him!*° and that had he
been she would have spoken to the mental health team and request them to assess him.’*'
Transcript of evidence, p457 Transcript of evidence, p473 Exhibit 49 — Statement of Ian Garlick dated 13 October 2014, Inquest Brief at p1540 Transcript of evidence, p470 Transcript of evidence, p315 Transcript of evidence, p304 Transcript of evidence, p305 Transcript of evidence, p327 Transcript of evidence, p337 Transcript of evidence, p338
She said it was not her practice to conduct a formal mental or mini-mental state
examination. *?
Management of opiate withdrawal
Dr Souvannavong completed a formal review of the incident by way of a Root Cause Analysis (RCA)'** on behalf of IHMS. The review found that the root causes of Mr Singh’s death could be identified in relation to the treatment and services provided by THMS.
However the RCA did identify that the management of opiate withdrawal was nevertheless a “contributory factor’, which was strongly disputed by Dr Shaw and Dr Parrish.’ Dr Shaw’s evidence was that the withdrawal symptoms were identified by Nurse Hubbard and she had implemented a management plan for Mr Singh’s planned withdrawal.'°
Nurse Hubbard was aware of Mr Singh’s Suboxone treatment and was worried he would experience withdrawal symptoms if he did not obtain his medication. She contacted Dr Shaw who in turn instructed her to contact the pharmacy to confirm they had a prescription. °° Dr Shaw suggested obtaining 3 days worth of Suboxone from the pharmacy to ensure Mr Singh had adequate supplies until she could review him.'?” Dr Shaw believed that if he did not receive his regular dose of Suboxone “he would likely go into rapid withdrawal, symptoms of which include diarrhoca, intense abdominal pains and sweating”.
Dr Parrish commented that from his review of the medical records and discussion with individuals involved in Mr Singh’s care he did not see any evidence of a failure to detect symptoms of withdrawal.’*° Rather he considered that the actions of Nurse Hubbard to obtain the Suboxone from the pharmacy were impressive considering how difficult that can be! 7 agree with Dr Parrish that the RCA was not accurate in relation to this issue.
THMS knowledge of Mr Singh’s previous suicide attempt
The evidence is clear that IHMS, as an organisation, had no knowledge of Mr Singh’s previous suicide attempt. Mr Singh specifically denied having any history of mental health issues or previous instances of self harm and there was nothing in his presentation to Nurse Hubbard, Nurse Garlick or Dr Shaw that raised concern for his welfare.
‘Transcript of evidence, p317
Exhibit 56 — Root Cause Analysis (Updated with completion of action plans)
The evidence also was that Dr Shaw and Nurse Hubbard were not interviewed as part of the RCA Transcript of evidence, p348
Exhibit 46 — Statement of Amy Hubbard dated 19 August 2014, Inquest Brief at p1471
Exhibit 46 — Statement of Amy Hubbard dated 19 August 2014, Inquest Brief at p1471
Exhibit 34 — Statement of Dr Emily Shaw dated 19 August 2014, Inquest Brief at p1491 Transcript of evidence, p550
Transcript of evidence, p551
144,
147,
Nurse Hubbard stated that had she known he had previously attempted suicide she would have been more extensive with her consultation.!*' She acknowledged Mr Singh’s death has
taught her to put more detail in her answers when making notes about the consultation?
Nurse Garlick also gave evidence that he had no information or indication that Mr Singh had previously sclf harmed and he commented that he did not have in his possession any
collateral information to that effect.’
Nurse Garlick said it is useful to have as much information as possible:
in my experience it’s not only useful it’s critical. ...one of the things I learned early on was that information is everything in dealing with ... assessments, that related to mental health and ...people ., have patterns of behaviour that they tend to repeat so if you can look at someone’s history it’s an indication of what’s going to happen in the ... present and in the future.“
Nurse Garlick said that if Mr Singh had informed him that he had previously attempted suicide he would have taken it very seriously and questioned him further, conducted a comprehensive tisk assessment and formulated a care plan for him which would include the allocation of a case manager.' Dr Parrish, Regional Director of IHMS, commented that information about Mr Singh’s previous suicide attempt would have resulted in an alternative course of action being taken.
He further stated: If we had known that Mr Singh had attempted suicide two or so weeks previously, that would have raised an immediate flag with us and rather than waiting for the routine mental health assessment in seven to 10 days or so time we would, in fact, have done an assessment immediately and have contacted our mental health person and we would [...] also have elevated the level of [...] awareness of risk for this gentlemen and we would have communicated that with Serco and DIBP. We would have spoken about this at the
PSP, [...] and we would have put him on a level of supportive management and engagement. M46
There is no doubt that information of Mr Singh’s previous suicide attempt was critical information and without that knowledge IHMS had an incomplete set of information as context to contemporaneously present clinical indicators and on which to base any. decisions
about medical and mental health management.
Transcript of evidence, p416 Transcript of evidence, p424 Transcript of evidence, p464 Transcript of evidence, p455 Exhibit 49 — Statement of Ian Garlick dated 13 October 2014, Inquest Brief atp1540 Transcript of evidence, p514
Obtaining collateral information from external agencies
153,
The second contributory factor identified by the IHMS RCA was that collateral information should have been obtained from previous health care providers. The DIBP review similarly commented that:
mental health assessments undertaken with Mr Singh relied solely on his presentation
during assessment and his response to questions. There is no evidence that any third party information was sought or used during these assessments. '*”
[...]
Medical practitioners who treated Mr Singh previously may not have been aware of any mental health issues, however information about his medical history would have been relatively straightforward to obtain given his drug dependency.'®
I note, however, that the DIBP Review acknowledges that medical records are not routinely obtained.
Dr Shaw indicated at Inquest that she had not contacted Mr Singh’s treating GP in the community and Mr Singh had not wanted to provide any details of his treating GP to her.
She said she thought it better for her to develop some rapport with him so that they could have an ongoing constructive doctor/patient relationship.“ However, Dr Shaw did agree that on occasion and when appropriate she would request contact with other health providers, but it would more usually be done by others within the organisation.!°°
The actual evidence of Mr Singh’s treating GP, Dr John Sherman, was that he could not really remember Mr Singh personally but his experience was that young Indian men are very coy about talking about their life’s journey; they usually obtained their script and left.'*! As a result, the information that could have been obtained from Dr Sherman was limited and would not have assisted in identifying any previous mental health issues or suicide risk.
Therefore, I did not consider the fact that the records of Mr Singh’s General Practitioner,
were not accessed, as identified in the RCA, was a contributing factor.
THMS access to RAPID Database
In contrast, Mr Singh’s previous suicide attempt and subsequent presentation at Casey Hospital on 27 December 2013 was likely to have been recorded in the Victorian Government “Redevelopment of Acute & Psychiatric Information Directions’ (RAPID) and
this possibility was discussed at Inquest and addressed in submissions.
ist
Exhibit 77 — DIBP Internal Review Death in Detention of Dalvir Singh, Inquest Brief at p367 Exhibit 77 — DIBP Internal Review Death in Detention of Dalvir Singh, Inquest Brief at p380 Transcript of evidence, p348 Transcript of evidence, p309 Transcript of evidence, p813
RAPID is available to mental health specialists in the public hospital system and is used in hospital emergency departments to assist with identifying patients that may have a history of mental health treatment in Victoria. The evidence is that IHMS do not have access to this system at immigration detention facilities.
Nurse Garlick described RAPID as “an essential piece of software”.'? Dr Parrish supported this stating that “this flow of communication is just so important in healthcare and I think I would strongly support having access to that database”.'? Dr Parrish indicated that IHMS
had unsuccessfully tried to obtain access to RAPID in the past.'*4
Enquiries were made by the legal representatives for THMS as to whether their client had prospects of gaining access to the RAPID database in the future. The response they received indicated that this would not be possible, principally because there are privacy reasons why IHMS, as a private organisation, should not have access to information of the confidential nature stored on the database. °°
I note that with respect to Mr Singh, the inability to access RAPID did not necessarily prevent IHMS practitioners from acquiring relevant historical mental health information, had his previous contact been known. In these circumstances, information is readily available from the service directly.
Furthermore, as I understand it, information contained in RAPID is limited to contact with public hospitals and therefore, in any event, does not provide a complete picture of mental health history. Thus, although I recognise that access to RAPID may be of some benefit to THMS practitioners operating in the detention setting, | do not consider that these benefits outweigh the very real concerns for the protection of the privacy and confidentiality of the information contained on the database.
On this basis, I did not consider it appropriate to call the Department of Human Services to
give evidence.
General comments with respect to the internal reviews
The DIBP Review of JHMS concluded that the mental health assessments, which indicated no concerns or issues about his mental state, appeared cursory and lacked any detail to justify that conclusion.“ On balance of evidence, and particularly in light of Nurse
Garlick’s significant experience as a psychiatric nurse, | do not support this conclusion.
Transcript of evidence, p469
Transcript of evidence, p516
Transcript of evidence, p516
Exhibit 84 — Letter from Moray & Agnew dated 28 November 2014
Exhibit 77 — DIBP Internal Review Death in Detention of Dalvir Singh, Inquest Brief at p1287
164,
T further disagree with the comment that:
It would appear that on this basis, noting that Mr Singh saw IHMS on at least a daily basis, that a more rigorous mental health screen and health assessment may have been warranted.'*?
In relation to the RCA, I note that it is unfortunate more of the clinicians involved in Mr Singh’s care were not interviewed and consulted as part of that process. I consider that
doing so would have been more consistent with best practice.
IHMS Changes to systems and processes
Chiron to Apollo
Dr Parrish told the inquest that IHMS have been providing health care in the immigration detention setting for approximately 10 years. He explained that CHIRON was an electronic health record system that had been in place for approximately eight years and at the time of its introduction was fit for purpose. In the years since its establishment, IHMS’s role has expanded and the immigration process changed, such that CHIRON was unable to cope with what was now required.
At the time of Mr Singh’s death, IHMS were in the process of moving towards a newer system called Apollo, which is an off-the-shelf database available to many health services within Australia.’**
The CHIRON system was user driven. It relied upon users to exercise discretion in obtaining relevant information to input. In contrast, Apollo prompts the provision of more detailed information and has more trigger questions. Further, Apollo includes a more structured and detailed mental health assessment template and requires clinicians to complete all key elements of the assessment, including a standard risk screen, with prompts
for further steps as required.’ According to Nurse Hubbard:
The new Apollo system is a lot clearer, it’s everything that you do from asking questions and what you observed but it’s actually a tick format, you mark off the question and you can not actually go onto the next thing.’
Nurse Garlick explained that it is a far more extensive process now. There are more detailed
questions and the clinician cannot move from one section to another until the previous
section is complete.'*!
Exhibit 77 - DIBP Internal Review Death in Detention of Dalvir Singh, Inquest Brief at p1287 Transcript of evidence, p503
Exhibit 77 —- DIBP Internal Review Death in Detention of Dalvir Singh, Inquest Brief at 1289 Transcript of evidence, p422
Transcript of evidence, p466
I consider that the change to Apollo should assist practitioners with conducting and recording a more comprehensive medical and mental health review and will strengthen the
integrity of this process.
Change to Mental Health Diagnostic tools
172,
173,
At the same time as IHMS was changing databases, they implemented new mental health screening tools.
In January 2014, IHMS reviewed and updated its policy regarding the use of diagnostic tools and the organisation now uses the Kessler 10 (K-10) scale and the Health of a Nation Outcome Scale (HoNOS),! which are preferred in the Australian community setting. 163
The K-10 is a simple, widely used self-report instrument. It is designed to measure psychological distress in the general population. The K-10 has been shown to be a good screening tool for detecting levels of distress that are associated with an independently determined diagnosis of an anxiety disorder and/or depressive disorder.
The HoNOS is a key clinician rating measure of problem severity that is used as a standard instrument by all Australian mental health services. The HoNOS is designed to capture a broad spectrum of information in a number of domains, not just symptoms. It has shown to be a reliable and valid instrument which is sensitive to change.'™
I consider that these changes mean the diagnostic tools are now in line with the Australian community approach and will help improve the mental health assessment process by IHMS
in detention centres.
I considered the following aspects of DIBPs involvement in Mr Singh’s care and management:
¢ Compliance Client Interview; ;
e Communication of information received from the AFP;
« Case Management; and =
e Changes to DIBP policies and procedures.
Compliance Client Interview
Mr Singh’s Compliance Client Interview (CCT) was conducted by Mr Cooper over the telephone for the purpose of establishing his identity, gathering information regarding his personal circumstances and making an assessment of those circumstances to determine his
Transcript of evidence, p467
16 Exhibit 90 - Inquest Brief at p4231 164 Exhibit 90 - Inquest Brief at p4231
immigration status. The aim of the interview was to make a preliminary assessment of
whether to continue Mr Singh’s current detention or to grant a bridging visa.'©
As part of the CCI, Mr Cooper completed a Preliminary Client Placement Recommendation (PCPR)'© and outlined Mr Singh’s reported health concerns, namely that he was on
Suboxone to manage his heroin addiction and this was recorded.
Following his interview with Mr Singh, Mr Cooper spoke with a member of Victoria Police (although he is unable to remember whom) and asked whether there were any violence or
‘67 He believed that the answer he received was ‘no’. !* At no point
behavioural concerns.
after this time was Mr Cooper advised about Mr Singh’s previous suicide/self harm attempt by Victoria Police.
Mr Cooper determined that Mr Singh was an “unacceptable risk to the community in terms of an integrity risk to the migration process”. However Mr Cooper assessed Mr Singh’s
transportation risk as low because he was cooperative and no concems had been raised.’
Mr Cooper further stated that if he had been told about a previous suicide attempt:
there would have been a lot more boxes checked, there’d be the self harm risk, health issues, the harm risk to or from others, suspected mental illness.'7!
I found Luke Cooper to be an honest and. credible witness who had considered the manner in which Mr Singh had been managed and offered the Court possibilities for improvements.
Subsequent changes to this process
In addition to the amendments to the Form 1275 discussed at paragraph 64 above, DIBP has modified the template email communication sent to police which now requests them to conduct appropriate checks on their systems and confirm in writing that those checks have been conducted.’ Specifically, the email now states: Please pay particular attention to Q.11 and ensure that any health / welfare / behavioural issues are clearly outlined. Please ensure that appropriate Police systems (and other
relevant data) checks are conducted and please advise us of any concerns immediately as the above-named person is now being held in immigration detention.‘”
Transcript of evidence, p23
Exhibit 9 - Preliminary Client Recommendation Report, Inquest Brief at p1354 Transcript of evidence, p26
Transcript of evidence, pp62 and 66
‘Transcript of evidence, p47
Transcript of evidence, p24
Transcript of evidence, p24
Transcript of evidence, p32
Exhibit 24 — New template email utilised by the ISS section (DIBP) when contacting Police to complete Form 1275, Inquest Bricf at p4216
Mr Cooper explained that on the new template email the above notice is in bold, red, and.
underlined and DIBP staff are told to: specifically remind police that once we’ve sent that email out to pay particular attention to the instructions in the email and to record any of that information on the form!
Sergeant Dawson agreed that this new process would be an improvement.'”
Communication between Danicl Schmidts and Victoria Police
188,
Mr Schmidts’ role was to work as a conduit between DIBP, Serco and law enforcement
agencies in relation to security and intelligence matters within the Mipc.!”
Mr Schmidts was in contact with Victoria Police on a number of occasions between January
and mid-February but no information regarding Mr Singh’s previous suicide/self harm
attempt was conveyed to him at any time.
As part of his role as SLO, Mr Schmidts reviews the completed CC] form for detainees to
identify whether there were any outstanding police matters. On 13 January 2014, Mr
Schmidts sent an email to Constable Osborne as a follow-up to his review of Mr Singh’s
CCI which indicated that Mr Singh had breached an intervention order and that there may be
outstanding police matters in relation to this.'’ According to Mr Schmidts, the purpose of
the email was to:
e advise Constable Osborne that Mr Singh was accommodated at the MIDC;
¢ obtain relevant information from Victoria Police about their dealings with Mr Singh; and
e ascertain whether there were any pending criminal charges, behavioural issues or health concerns so that they could ensure he was managed appropriately. hd
On 15 January 2014, Constable Osborne provided a response to DIBP which noted that Mr
Singh was the subject of an intervention order, pending criminal charges for multiple
breaches of the intervention order and the associated court dates.’ However, Constable
Osborne’s email was silent as to whether there were any behavioural issues and it did not
mention his previous suicide/self harm attempt.
Contact with respect to the ongoing breaches of the FVIO
On 5 February 2014, Mr Schmidts had a conversation with Constable Marshall who advised him that Mr Singh had been repeatedly contacting Ms Bala in breach of the FVIO while in custody at the MIDC. Constable Marshall sought information from Mr Schmidts concerning to the possibility of Mr Singh being deported and whether DIBP were in a position to
Transcript of evidence, p38
Transcript of evidence, p260
Exhibit 65 — Statement of Daniel Schmidts dated 14 October 2014, Inquest Brief at p2029 Exhibit 65 — Statement of Daniel Schmidts dated 14 October 2014, Inquest Brief at p2030 Exhibit 65 -- Statement of Daniel Schmidts dated 14 October 2014, Inquest Brief at p2030 Exhibit 65 — Statement of Daniel Schmidts dated 14 October 2014, Inquest Brief at p2030
restrict his phone access. Mr Schmidts advised Constable Marshall that they would be unable to restrict or monitor access to his telephone in immigration detention. Mr Schmidts then relayed this information via an email to Mr Singh’s case manager, Julie Gambrell.!®° 1
do not consider this to have becn an unreasonable response in the circumstances.
Communication of information received from the Australian Federal Police (AFP)
192,
194,
As part of the MIDC induction process, facial and fingerprint biometrics are acquired from all detainees. The biometrics are compared to departmental identity records as well as law enforcement databases including the NAFIS. When a positive biometric match occurs, a request is made to the AFP for relevant information pertaining to that individual.!*!
On 21 January 2014, after conducting a fingerprint check, the AFP sent an email to DIBP attaching a fingerprint and criminal history check in relation to Mr Singh. The covering email did not specifically draw attention to any risk of suicide and self-harm nor did it contain specific information relating to the suicide attempt made by Mr Singh while in police custody however it did include a line in red text that stated:
PLEASE NOTE: Detainee has as serious criminal history recorded in VIC, please also note the warnings recorded. !*
However, a warning for suicide/self harm was included in an attachment to the email.
DIBP did not make any further request to the AFP or Victoria Police for any additional information in relation to this note nor did they forward this information to Serco or IHMS.
The evidence is that whilst the AFP email was sent to generic mailboxes, a number of individual DIBP personnel did receive the email, including Mr Kingma, Mr Schmidts and Ms Gambrell. Importantly, this was the first time DIBP had been Provided with information about Mr Singh’s previous suicide/self-harm attempt.
The evidence is that, as Mr Singh’s police history was known to DIBP staff and he had already been in detention for 10 days, displaying no indications of self-harm or suicide, the information was only noted and not referred to either IHMS or Serco.’ Mr Kingma did not
read the email at all. **
Mr Schmidts did not read the email!® and did not take any action in relation to it because he had already made contact with and received information from Victoria Police.’8° Mr
182,
Exhibit 65 — Statement of Daniel Schmidts dated 14 October 2014, Inquest Brief at p2030
Exhibit 77 — DIBP Internal Review Deuth in Detention of Dalvir Singh, Inquest Brief at p1287
Exhibit 67 — Email from Identity Resolution Centre to DIBP on 21 January 2014, re fingerprint criminal history, inquest brief, p2043
Exhibit 77 — DIBP Internal Review Death in Detention of Dalvir Singh, Inquest Brief at p379
A full audit of AFP fingerprint/criminal history checks was conducted as a result of this incident and confirmed that the information provided in all other AFP emails had been provided to DIBP, Serco and IHMS, Exhibit 75, ~ Statement of Michael Kingma, dated 21 August 2014, Inquest Brief at p1284
Transcript of evidence, p597
Schmidts also noted that there was no procedure in place for how this type of information should be managed internally within DIBP.'®” In evidence, he acknowledged he should have read it and verbally notified IHMS.!®8
Ms Gambrell remembers receiving the email and reading the alerts.’® She realised tho information was new, however did not communicate it to IHMS. She noted that it was common practice for the case manager to review the form for any alerts, raise any issues with THMS and record information on the detainees file however she believed no furthcr action was required’? because Mr Singh was already engaged with IHMS and she mistakenly assumed this information would be known by them. She commented that:
if Mr Singh had not already engaged with IHMS, [she] would have immediately raised
these warnings with the IHMS medical and mental health team. However, as Mr Singh
had already been engaging with IHMS, and he was already aware of the support services
... available...., I was not required to action any referral to THMS in relation to the warnings recorded.!*!
Ms Gambrell acknowledged in hindsight that not actioning this email created an information
gap, |"
Changes made to the process of communicating information from the AFP
The issue of the transfer of information received from the AFP was identified during the DIBP Review and was acknowledged in submissions made on behalf of DIBP. At the time of Mr Singh’s death there was no documented procedure for handling this information and therefore depended on the judgement and discretion of the officers who received it, One of the central issues identified was that there was no single point of accountability.”
Mr Florent gave evidence that this is no longer the case. A procedure was implemented to ensure that this type of information provided through the DIBP identity resolution process is considered and actioned by relevant staff in detention facilities and passed on to service providers, as appropriate. m4
Ms Gambrell confirmed that the new process requires the Case Manager to review the
document and look for any new information, particularly whether there are any alerts and/or
Exhibit 65 — Statement of Daniel Schmidts dated 14 October 2014, Inquest Brief at p2030 Transcript of evidence, p597
Transcript of evidence, p613
Transcript of evidence, p644.
Exhibit 69 — Statement of Julie Gambrell dated 18 August 2014, Inquest Brief at p1249 Exhibit 69 — Statement of Julie Gambrell dated 18 August 2014, Inquest Brief at p1250 Transcript of evidence, p646 .
Exhibit 77 — DIBP Internal Review Death in Detention of Dalvir Singh, Inquest Brief at p366 Exhibit 79 — Statement of Daniel Florent dated 14 July 2014, Inquest Brief at p1056
warnings. Where a warning is noted, the case manager will communicate with stakeholders including IHMS and Serco to confirm their awareness of the alert or warning,’™*
Case management
204,
Ms Gambrell’s role as Mr Singh’s case manager was to assist him to resolve his immigration status in a fully informed manner consistent with legislation and government policy. Further, it was to monitor the health and welfare of Mr Singh in association with the MIDC stakeholders and DIBP.'%
Ms Gambrell first met Mr Singh on 14 January 2014 and they discussed various subjects including the fact that he was separated from his wife and had a son. Apart from the intervention order, Mr Singh claimed to have no criminal or domestic violence history. He confirmed that he was engaged with IHMS for his drug dependence issues and for mental health support. However, Ms Gambrell did not have access to information held by IHMS in relation to Mr Singh and, in particular, did not have a copy of the relevant mental health
assessments. '?”
During this initial meeting Ms Gambrell also discussed Mr Singh’s immigration pathway and noted that at that time his intentions were unclear. Mr Singh did not want to return to India and Ms Gambrell said that he wanted to seek legal advice so she provided him contact numbers for this purpose. The evidence is that between 14 and 21 January, Ms Gambrell
saw Mr Singh more than any other detaince.'8
Changes to DIBP policies and processes
DIBP provided the court with a copy of their internal review which resulted in a number of changes to DIBP policies and procedures since Mr Singh’s death including:
e The Revised Form 1275.
e The amended template email sent by DIBP to Victoria Police when sending Form 1275.
e New procedure regarding receipt of emails from the DIBP Identity Resolution Centre; and
e The development of a new strategy: Building PSP Capacity 2014-2015 Policy: A Plan to build staff capacity to apply the Psychological Support Program and. mental health policies.
In addition, submissions on behalf of DIBP outlined the following changes currently being
considered:
e Information sharing between DIBP, AFP and Victoria Police generally, and specifically a review of the MOU, was to occur in February 2015.
(97
Exhibit 69 -- Statement of Julie Gambrell dated 18 August 2014, Inquest Brief at p1254 Inquest Brief at p1246
Transcript of evidence, p639
Transcript of evidence, p 685
¢ Inquirics made regarding access to the RAPID database, however DIPB have been advised that direct access cannot be permitted due to privacy concerns associated with the sensitive nature of the records; and
e Finalisation of the Continuity of Care Policy regarding general health issues which does not cover mental health issues.
Psychological Support Program Meeting
211,
PSP meetings are held every day at the MIDC with employees of DIBP, Serco and JHMS in attendance. The requirements for the operation of the PSP is set out in Chapter 6 of the DSM including that the meetings are led by a senior clinician from IEMS.' Ms Gambrell attested that “we will discuss and raise anyone of concern or anyone with changed behaviour
that we wanted to alert each other of for the day”.?”
Mr Singh was discussed at the PSP meeting on 29 January 2014. Ms Gambrell raised with those present that Mr Singh’s wife had attended MIDC for a pre-arranged visit, Mr Singh had not been permitted to talk with his wife during the visit and this had seemed to aggravate him. She requested that stakeholders be aware of this and monitor him.”
Ms Gambrell said “that was the only sort of out of character behaviour that I witnessed the whole time with Mr Singh...That was the only time I ever saw a variance of his behaviour”?
DIBP and Serco staff were interviewed as part of the DIBP Review process which indicated that a consensus was reached between participants at the meeting that whilst Mr Singh seemed annoyed at times during the visit with Ms Bala, he had coped well with no ongoing
concerns.2™ No further action was taken except to update Mr Singh’s ImMp2™
Preventative Health Meetings .
Another forum for discussion and review of detainees is the Preventative Health Meetings (PHM), which are held every fortnight with employees from DIBP, Serco and IHMS in attendance,> On 7 February 2014, Ms Gambrell raised Mr Singh for discussion as a result of his upcoming voluntary removal and alleged breach of the FVIO.""
The decision concerning whether Mr Singh should be placed on ongoing monitoring alert after this meeting was made by IHMS, who determined that this was not necessary.”
Exhibit 66 — Chapter 6 of the Detention Services Manual — Psychological Support Program, Inquest Brief at p1073; Transcript of evidence, p652
Transcript of evidence, p651
Exhibit 69 — Statement of Julie Gambrell dated 18 August 2014, Inquest Brief at p1253
Transcript of evidence, p668
Chapter 6 of the Detention Services Manual — Psychological Support Program, Inquest Brief at p1080 Exhibit 81 - Statement of Johnathon Holmes dated 15 July 2014, Inquest Brief at p252
Exhibit 70 — Supplementary statement of Julie Gambrell dated 22 November 2014, paragraph 5
Exhibit 70 — Supplementary statement of Julie Gambrell dated 22 November 2014, paragraphs 3 and 6 Submissions on behalf of DIBP, p13
214, 215.
I find that Dalvir Singh died on 13 February 2014 from ia) HANGING.
I further find that Mr Singh intentionally tied a bed sheet around his neck and secured it to the bunk in his room from which he suspended himself with the intention of causing his own death.
No one single factor accounts for Mr Singh’s decision to take his own life. Rather it can be understood in the context of a combination of personal stressors, including a previous suicide attempt in custody, the breakdown of his relationship and separation from his son, the consequences of his alleged perpetration of family violence, his withdrawal from opiate
dependence and immigration detention.
Although a number of deficiencics have been identified, particularly in relation to communication of critical information between agencies, I do not consider any to have contributed in a significant way to his death. However, the circumstances of Mr Singh’s death provide a good opportunity to reflect on current practices and procedures of those agencies involved in providing services to people in immigration detention.
Findings in relation to Victoria Police
220,
I find that Victoria Police did not communicate knowledge of Mr Singh’s previous suicide verbally or in writing to Mr Cooper on 10 January 2014.
I am unable to determine on the balance of probabilities whether Sergeant Dawson conveyed information about Mr Singh’s previous suicide attempt to either Serco officer at any time during the transfer process. However, it is evident that the information was not formally documented at the time and therefore valuable insight into the way Mr Singh’s immigration detention should and could have been managed was lost.
I find that Victoria Police had no documented process, procedure or system in place to guide its members on how to adequately transfer critical information about Mr Singh to Serco and
Findings in relation to Serco
223,
I find that Serco employees who engaged with Mr Singh were unaware of his previous suicide attempt whilst in police custody.
I find that no Serco employee who observed or interacted with Mr Singh were concerned about his mental health or wellbeing or that he was at risk of self harm during his time in detention. In fact the evidence demonstrates that he participated in programmes and activities and he was intcracting well with other detainees.
Documentation completed by Serco employees, particularly the Self Harm Risk Assessment Interview, lackcd adequate detail. However, | find that Mr Singh was subsequently reviewed on a number of occasions by mental health professionals and I therefore find that there is no
224,
direct relationship between the manner in which the Self Harm Assessment Interview was conducted and Mr Singh’s death.
On the balance of probabilities and on the evidence before me, I find that Serco’s general care and management of Mr Singh whilst in detention at the MIDC was appropriate in the
circumstances,
Findings in relation to THMS
225,
227,
228,
I find that IHMS did not receive any information in relation to Mr Singh’s previous suicide attempt either from Mr Singh himself or from other agencies in possession of that information. When interviewed by the health nurse, general practitioner and psychiatric nurse, Mr Singh did not present as depressed or otherwise unwell and when prompted specifically denied any thought or intention of self harm or suicide. On this basis, I find it reasonable that none of the IHMS clinicians identified the potential that he was suffering from an undiagnosed mental illness or that there was an acute risk that he might engage in self harm or suicidal behaviour.
I accept the evidence that had the information about his previous suicide attempt been known, the overall strategic management by IHMS would have been different.
I acknowledge that the THMS Root Cause Analysis identified the management of Mr Singh’s opiate withdrawal and not having sought collateral information from previous health care providers as problematic. With respect, I do not agree. Indeed I find that Mr Singh’s opiate withdrawal was quickly identified and managed in a proactive way, in particular by Nurse Hubbard. Further, in relation to obtaining collateral information from the GP, I find that although good practice, it would not have disclosed any information in relation to Mr Singh’s mental health.
I farther acknowledge that IHMS have implemented changes to their computer system and mental health assessment tools in line with those used in the community. T commend IHMS for their commitment to continuous improvement in their systems and processes.
Based upon all of the cvidence, I find that the medical and mental health care and management provided to Mr Singh by IHMS was reasonable and appropriate in all of the
circumstances.
Findings in rclation to DIBP
The attachment to the AFP email to DIBP on 21 January 2014 contained a warning about Mr Singh’s history of self harm. I find that the email was not actioned by any employee of the DIBP. | further find that there was a lack of appropriate systems or processes in place to guide the management, action and communication of new and critical information about a detainee. In particular, at the time of Mr Singh’s death there was no single point of accountability for reading and actioning this information. This is unfortunate because it was
the first time this information had been provided to DIBP and it was another missed opportunity for this information to inform his management whilst in detention.
Although I am unable to find that, had this information been actioned, Mr Singh’s death would have been prevented, the evidence is that it would have triggered a different response and management plan. However, I am satisfied that DIBP have taken appropriate measures to remedy this process breakdown to ensure that this situation does not occur again.
It is clear that DIBP have taken a proactive approach to the death of Mr Singh and implemented a number of changes to their policies and procedures. They are to be commended for their approach to the inquest in terms of providing documents, information, policies and procedures and what appeared to me to be full and frank disclosure to my
investigation.
Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments
connected with the death:
Recognition of the multiple vulnerabilities experienced by immigration detainees is an essential first step in the provision of appropriate care and management. Many of these paths of vulnerability are common to all detainees including estrangement from family, friends and community, uncertainty about the future, and loss of liberty and control over their personal circumstances.
The importance of applying an understanding of these vulnerabilities when working with detainees cannot be understated and foreshadows the need to take positive action towards ensuring that this translates into effective policies and procedures for the promotion of health and well being.
In light of this, effective communication between and within agencies involved in the immigration detention process is imperative because without a complete picture, assessment and management of the risk of suicide or self harm at any one point in time becomes more difficult.
Although a coronial investigation is a stressful process, it was made considerably easier by the open and transparent manner in which it was approached from the early stages by the Interested Parties and witnesses alike. In particular, it was encouraging to see that some of the Interested Parties were pro-active in identifying and modifying areas that required improvement.
RECOMMENDATIONS 234, This inquest focussed on Mr Singh’s care and management and in general highlighted the importance of effective interagency communication and adopting a coordinated approach to
the immigration detention process.
Department of Immigration and Border Protection, Serco and Victoria Police Recommendation I
To promote the safety and wellbeing of immigration detainees, I recommend that appropriate representatives of the Department of Immigration and Border Protection, Serco and Victoria Police meet to discuss and develop a coordinated transfer of custody process which ensures that all relevant information held by one agency is conveyed contemporaneously with the detainee when transferred.
Recommendation 2
To ensure the efficacy of any interagency coordinated transfer process, I recommend that the Department of Immigration and Border Protection, Serco and Victoria Police each independently ensure that any necessary internal policies and procedures are effectively developed and implemented.
Recommendation 3
To ensure the efficacy of any interagency coordinated transfer process that is developed, I recommend that Department of Immigration and Border Protection, Serco and Victoria Police each ensure that their employees are aware and appropriately trained in the aspects of the process pertaining to them.
Serco and the Department of Dnmigration and Border Protection Recommendation 4
I recommend that Serco and the Department of Immigration and Border Protection collaborate to amend the Self Harm ‘Assessment Interview to require all detainees to be specifically questioned about their mental health and suicide and self-harm history, to ensure that any relevant information is elicited and recorded at the earliest available opportunity and appropriately actioned.
International Health and Medical Service Recommendation 5
To increase the safety of detainees, I recommend that the Department of Immigration and Border Protection, Serco and the International Health and Medical Service meet to consider the feasibility of, and options around, developing a system whereby qualified mental health practitioners are able to observe and interact with detainees within the common areas of the Maribyrnong Immigration Detention Centre, particularly during periods of higher suicide and self harm risk such as when first detained or when informed about deportation or when identified as someone who is at risk.
Pursuant to section 73(1) of the Coroners Act 2008, I order that finding be published on the internet. ,
I direct that a copy of this finding be provided to the following: ° Senior Next of Kin, Ms Bala; : ° The Chief Commissioner of Police; . Serco Australia Pty Ltd; ° The International Health and Medical Service; and . The Department of Immigration and Border Protection.
Signature:
at he aay ais Oat
Jacqni Hawkiny’ emer a]
Coroner
Date: 26 March 2014
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