A NSW Coroner has issued a scathing report into the suicide deaths of three men within three months at the Villawood immigration detention centre in 2010, listing systemic failings by the department and the private company that runs the centre.
The Coroner, Mary Jerram, also rejected claims by the immigration department that it wasn't within her power to make recommendations to the federal immigration minister Chris Bowen.
She has recommended Mr Bowen overhaul procedures for the forced removal of immigration detainees - including making it clear when officers should abort a removal.
She has asked Mr Bowen to prohibit the department from notifying detainees of negative decisions or forced removals on Thursday or Friday, and change the governance structure of mental health services at Villawood so a psychiatrist is put in charge.
Trained police officers should also be used to advise negotiators in high-risk situations, such as when a detainee is threatening to jump from a balcony, the recommendations said.
The report found Josefa Rauluni, a Fijian national, jumped to his death as he was being removed. Ahmed Al-Akabi, an Iraqi asylum seeker, and David Saunders, a Briton, hung themselves from the shower.
"In all three deaths, some of the actions of some staff were careless, ignorant or both, and communications were sadly lacking," the coroner said.
She blamed the failure of the system, rather than individuals, and said policies and protocols were ignored.
The staff of Serco, the company which runs the detention centre, were completely untrained and unprepared in dealing with Mr Rauluni when he threatened to jump from the balcony, she said.
Mr Al-Akabi was probably misdiagnosed and medicated and no action was taken to assist his mental deterioration after almost a year in detention, the coroner found. The contracted health company, IHMS, "failed in its duty of care" and its system was under-resourced and under stress".
She said it was meanwhile "deplorable" that Mr Saunders wasn't put on suicide watch.
People in immigration detention are at "much greater risk of suicide" than the general community, because of feelings of helplessness and frustration that can exacerbate depressive disorders, she said.
"When a government choose to maintain a detention system, it carries a heavy responsibility. Similarly, a company which contracts to shoulder a large part of that responsibility is under a major obligation to fulfil its contract... it cannot be said that either DIAC or Serco met those responsibilities in full," she said.
Since the three incidents in 2010, another man, Tamil refugee "Shooty" Vikadan, has taken his life by ingesting poison at Villawood in October 2011.
The coroner's findings will add to the condemnation by 30 mental health groups on the standards of mental health care in immigration detention.
Kirsty Needham is the Herald's Immigration Correspondent
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