A Coroner has ruled that the death of a Kiwi in an Australian detention centre was caused in part by "physical and emotional distress arising from his involvement in a fight".
Robert Peihopa, 42, died on April 4 last year at the Villawood Immigration Detention Centre in Sydney.
He had been detained at the centre for almost 10 months awaiting deportation on character grounds, after he was convicted of multiple criminal offences.
Peihopa was transferred to Villawood after serving time in prison for reckless driving under the influence of drugs.
An inquest into his death was held in Sydney in September.
The inquest heard that Peihopa was a long-time user of the drug ice and had used it both in prison and while at Villawood.
Autopsy results revealed at the inquest showed Peihopa died from "methamphetamine toxicity" that had complicated "ischaemic heart disease".
Soon after he died Peihopa's mother Hera was told by authorities that he died of a heart attack after a "sparring session" in the detention centre's gym.
New South Wales Deputy State Coroner Magistrate Teresa O'Sullivan released her inquest findings today.
She ruled Peihopa's cause of death was fatal cardiac arrhythmia
His manner of death was "underlying chronic coronary artery disease and triggers of ingestion of methamphetamine in the hours before Mr Peihopa's death and the physical and emotional distress arising from his involvement in a fight immediately prior to his death."
Magistrate O'Sullivan said after hearing from experts during the inquest she was satisfied that Peihopa's "involvement in a physical fight may have been a trigger".
"I find that the fight, the methamphetamine and the underlying heart disease all contributed to Mr Peihopa's death," she said.
The fight happened in a room occupied by two other Kiwi detainees.
Another detainee told the inquest that he did not see any fight but gave evidence that confirmed it had taken place.
"He gave evidence of tensions between (another detainee) and Mr Peihopa; of hearing noises emanating from Unit 3 consistent with a fight; of seeing detainees running out of room 2 of Unit 3; of seeing Mr Peihopa breathless on a chair; and of seeing fresh injuries on (the other detainee) the following day," Magistrate O'Sullivan said.
"There is no direct witness to the fight, but many witnesses gave evidence which supports the conclusion that a fight involving Mr Peihopa occurred.
"Detainee Dave Callaghan - who is no longer in Australia - said to police (that he) heard loud noises coming from room 2 below him, which sounded like chairs being thrown around and male voices shouting.
"At around 8.30pm he saw Mr Peihopa come out of room 2 and sit down at the dining table to try and catch his breath. He saw Mr Peihopa go outside and stumble."
Magistrate O'Sullivan detailed Peihopa's death.
She said CCTV footage showed a man fitting Peihopa's description collapsing.
"This CCTV footage shows that subsequently, other unidentified people attempt to lift him up and place him on a chair," she said.
"CCTV footage shows that at least two separate people sought to pick Mr Peihopa up once he had collapsed at around 9.26pm."
She said a guard also tried to put Peihopa on a concrete path in the recovery position and went to get pillows.
"Based on the CCTV footage seen in the light of witness testimony, it is most likely that the fight had finished by 9.26pm and that by that time Mr Peihopa had come outside to catch his breath.
"At 9.43pm, Serco guards responded to his collapse."
Magistrate O'Sullivan made a number of recommendations as a result of Peihopa's death.
Those included:
• The Department of Immigration and Multicultural Affairs and Serco each reviewing the circumstances of this matter and give consideration to whether there are sufficient staff to provide an adequate level of supervision and security.
• The Department develop and make available a rehabilitation programme specifically targeted at ice users at the detention centre.
• The Department should investigate ways to facilitate drug and alcohol rehabilitation programmes being provided to detainees who require them.
• Serco should review the way in which it manages intelligence holdings suggesting detainees are using illegal drugs or alcohol in order to ensure that adequate supervision arrangements are in place in relation to such detainees.
• The Department should investigate with NSW Corrective Services and NSW Justice Health options for obtaining information from them about a detainee's custodial history including information regarding their behaviour while in custody, health and welfare and any history of drug and alcohol use,
• The Department and Serco should develop a protocol for notifying in a timely manner the next of kin of the death of a detainee, and a representative of both the Department and Serco should communicate with the next of kin to acknowledge with appropriate sensitivity the death of their loved one while in Serco and the Department's care and control.
The last recommendation came as a result of Peihopa's mother and partner giving evidence about how they found out about his death.
"Mrs Hera Peihopa, gave evidence that she was first notified of her son's death via messages from other detainees," Magistrate O'Sullivan said.
"She repeatedly called Villawood that evening and into the early hours of the following morning.
"She was told that someone would call her back but no-one did.
"It can only be imagined how distressing this was for her. Eventually, the NSW police informed her of her son's death."
Villawood's Inspector of Detention Operations Kerrie Pennell said the family could not be informed as she "could not get access to the visitor logs to find Peihopa's next of kin".
"She also said in oral evidence that there was no written policy that it was the responsibility of the Department to notify the next of kin of a death in detention."
Magistrate O'Sullivan said Pennell was incorrect on that fact.
"The Department's "Death in Detention" procedure provides that "the department's centre manager is responsible for notifying the next of kin in the event of a death".
"She agreed that there might be a role for the development of a departmental protocol for notifying next of kin in a timely manner."
After the release of the findings Hera Peihopa released a statement to the Herald.
She thanked the Coroner for her findings but reiterated her criticism of the detention centre, Serco and the Australian Government.
"During the Inquest in September I sat in the courtroom and listened as people who work for the Department of Immigration and the people from Serco tried to pass the buck and say they were not responsible for Robert's death," she said.
" What we learnt … was that ... Serco really doesn't give a damn about the detainees.
"One of the Serco officers said his job was to be little more than a baby-sitter.
"Evidence came out that basically nobody who was involved in the management and supervision of my son inside Villawood had the slightest understanding about what is required to supervise and care for the health and welfare of detainees."
Hera Peihopa said since her son's death "not one person from Serco or the Department has called me or spoken to me or written to me to say they were sorry about Robert dying on their watch".
"My son was dead inside Villawood and all I got – all my family got – was arrogant indifference shown by Serco officers and the Department."
Hera Peihopa called for more answers - particularly around why her son was at Villawood.
Despite being born in New Zealand he had lived across the ditch since he was 17.
"I think it is a terrible injustice that Robert was placed in Villawood Immigration Detention Centre at all - after all he was virtually an Australian.
"So why did the Australian Government want to throw him out of his own country and away from his family?
"I call on Malcolm Turnbull and Jacinda Ardern to sit down and stop this crazy situation.
"No two countries in the world are as close as Australia and New Zealand. So why does Australia throw a New Zealander who lives in Sydney into immigration detention and try to deport him?"
The huge prize will jackpot to Wednesday night's draw.