Serco,awarded the $4 billion cumulative contract to run services in onshore detention,declined to comment until a coronial investigation was complete but expressed condolences to Kellie’s family.

International Health and Medical Services referred questions to Australian Border Force,which said it could not comment on individual cases,but defended the “high quality” services provided in immigration detention.

‘There was no common picture of the risks involved in Mr Kellie’s care.’

Detention Assurance Team ‘sensitive’ report

“The ABF and the Department of Home Affairs are committed to the welfare of detainees within Australia’s immigration detention network and take all reasonable steps to provide a safe environment to prevent injury and death in immigration detention facilities,” a department spokesperson said.

Australia’s immigration detention population has undergone significant changes in the past decade,with more than 90 per cent of detainees now having a criminal record. This followed laws introduced in 2014 that mandate visa cancellations for non-citizens sentenced to 12 months prison.

Prison psychiatrists who reviewed Kellie in 2016 after he self-harmed found he was at “high risk of relapse if his medication discontinues” and documented a history of psychosis,drug use,violence and self-harm.

Despite this,upon transfer to Villawood,a Serco risk assessment recorded that he had no history of violence,drug use or self-harm. Less than one week after arriving in the detention centre,he attempted suicide by hanging but was revived after CPR was performed.

The review found that over the next three years,multiple processes failed to ensure Kellie received anti-psychosis medications – once for a period of 82 consecutive days – exposing him to heightened risk of self-harm.

International Health and Medical Services told the review its IT systems only alerted staff when “life sustaining” medications,such as insulin,are skipped. “Mental health medications are not on the alert system,due to the high number of detainees taking mental health medication,” the report found.

During the same period,Kellie either cancelled or missed up to 10 medical appointments. International Health and Medical Services policies require detainees be sent a letter after three medical appointments are missed. This did not occur in Kellie’s case,according to the report.

The disruption in Kellie’s medication regime and medical care was not reported at daily or weekly stakeholder meetings,the report found,so the people responsible for his care were unable to proactively manage his risk of self-harm.

In 2019,a psychiatrist assessed Kellie to be in an acute state of psychosis. He spent one week in Liverpool Hospital and was discharged with a medication plan and instructions,neither of which were followed.

The report found Villawood did not stock the prescribed medication,and had no back-up plan to source medications when the local pharmacy was closed. Six days after Kellie was released from hospital,he was found hanging in the bathroom of his cell and pronounced dead shortly afterwards.

A 2013 Commonwealth Ombudsman review found immigration detention for longer than six months has a “significant,negative impact on a detainee’s mental health”. It found poor data collection and governance arrangements within the department and its service providers had contributed to a spike in detainee self-harm and suicides.

The Detention Assurance Team report made eight recommendations,all of which were risk-rated high,which meant if left untreated,there would be “major” consequences.

‘Sometimes I thought that I was the only person checking up on him.’

Moses Kellie’s friend in detention

One key recommendation was for International Health and Medical Services to urgently create an alert system for skipped schizophrenia medication and specialist medical appointments.

“The extent of the problem was not detected,as there was not a system in place,” it found.

Other recommendations included additional training and a system to track high-risk detainees at weekly stakeholder meetings.

As part of the same process,the Detention Assurance Team also completed a shorter review of Aljaberi’s treatment,finding aspects of his treatment warranted greater consideration by the department and its service providers.

It was also not clear that Serco had sufficient history of Aljaberi’s vulnerabilities and risks. The Detention Assurance Team again found there was no evidence of an adequate handover between NSW Corrections and the department.

It found Aljaberi accessed crystal methamphetamine in Villawood,but there were no efforts to disrupt this. While Aljaberi had seen a drug and alcohol nurse four hours before his death,this lasted only six minutes. The Detention Assurance Team said the “clinical adequacy” of this appointment should be assessed.

The Detention Assurance Team noted the Chief Medical Officer was chairing a critical incident review of Aljaberi’s treatment and may consider his case as part of the team’s broader review into suicide and self-harm in the immigration detention network.

A Coronial inquest started on Monday in Sydney examining the suicides of three Villawood detainees between January 2019 and May 2022,including Kellie.

It will explore common issues including mental health monitoring,treatment and support and information sharing between authorities.

Counsel assisting the coroner Adam Casselden,SC,said Kellie was said to have been a quiet man who preferred to keep to himself,and attended Catholic and Hillsong churches.

He said a Serco employee described Kellie as a “very good artist”,while an International Health and Medical Services nurse thought he was a “kind and polite person” and never experienced him being aggressive or difficult.

Casselden anticipated one witness would say they observed “sadness in him always”.

Giving evidence via telephone,Kellie’s former detainee friend said they would play soccer and volleyball at Villawood,and he noticed Kellie withdrawing from people and becoming depressed in August or September 2018.

“He stopped coming out to lunch,he stopped coming out to activities,he stopped talking to our circle of friends. And he was in the room,all the time,” the man said.

In the following months,he said Kellie “stopped taking care of himself” and stopped eating,and said twice he was “going to kill himself”.

The witness said he encouraged Kellie to write a note with his name,date of birth,how he was feeling and that he needed some mental help. He said he passed Kellie’s note to a detention worker who ended up calling his manager for the day.

In evidence,the witness said:“Sometimes I thought that I was the only person checking up on him.”

The inquest will continue through the month,looking at the treatment of other detainees,Leah Porter and Muhammad Hafizuddin bin Zaini,whose deaths were in 2022 and 2020 respectively in Villawood.

Porter’s visa had been cancelled after serving 12 months in prison for assaulting a police officer. She had lived in Australia for more than a decade and had two adult children. Her relativestold media last year she “should never have been in detention” and her mental illness became worse when she didn’t take prescribed medication.

Hafizuddin died aged 29 as he waited to be deported to Malaysia after he was found to outstay his visa. Detaineestold media Hafizuddin had agreed to be deported but the delays in detention caused anxiety and depression.

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