The Palmer Report, or the report of the Inquiry into the circumstances of the Immigration Detention of Cornelia Rau, is damning. And so were the conclusions in the media reports and opinion pieces. But, as we expected, nobody could trump the excellence and thoroughness of the Sydney Morning Herald reporter David Marr, who over two days wrote an analysis of the report, interspersed with his own observations based on his contacts with refugee advocates and his highly developed skills, both as a writer and inquirer.
Cartoon: Thanks to The Australian's cartoonist Bill Leak.
Thank you, David. Our hats off for the high excellence of your work.
Below are David's two contributions to the body of knowledge of Australia's shocking treatment of immigration detainees.
27 August 2005: Don't ask too many questions: the story of DIMIA's cover-up of the Vivian Alvarez affair - this is a copy of a 2-part article from the Sydney Morning Herald, written by investigative reporter David Marr: "The lies that kept Vivian Alvarez hidden for years" and "The cover-up comes unstuck".
2 September 2009: In 2009, it's getting crowded on Christmas Island - Slowly Christmas Island is filling up with refugees - but in August 2009 it seemed that senior and high-profile advocates all flocked to the place. Human Rights Consultation Chief Frank Brennan, Psychiatrist Louise Newman, and Sydney Morning Herald Journalist David Marr all looked in on the bizarre scenery.
2 June 2007: David Marr: Careful, he might hear you - John Howard has ... cowed his critics, muffled the press, intimidated the ABC, gagged scientists, silenced NGOs, censored the arts, prosecuted leakers, criminalised protest and curtailed parliamentary scrutiny, and this has happened because we let it happen.
27 August 2005: Don't ask too many questions: the story of DIMIA's cover-up of the Vivian Alvarez affair - this is a copy of a 2-part article from the Sydney Morning Herald, written by investigative reporter David Marr: "The lies that kept Vivian Alvarez hidden for years" and "The cover-up comes unstuck".
14 April 2005: Geneva versus Canberra: Australia in the dock at the UN - The UN has again attacked the Howard Government's record on race, but this time the politicians are shutting up and news of the verdict isn't getting out. Back in 2000, the UN was unimpressed - and that's the Geneva problem in a nutshell: what works in Canberra doesn't work in in this town. The Howard Government message carries no particular clout. The power of jobs and patronage, so persuasive back home, has no impact in Geneva.
29 September 2004: The Shape of the Argument: The 3rd Overland Lecture - David Marr delivers the lecture: "After nearly a decade of sustained bullying from government [...] the media is in a quandary, has lost its edge. Not everyone, not everywhere. But it has happened. What I am exploring here is how that loss of confidence has come to shape public debate..."
27 May 2003: The Role of the Writer in John Howard's Australia - The Colin Simpson Lecture in the Redfern Town Hall. "I have a simple plea to make: that writers start focusing on what is happening in this country, looking Australia in the face, not flinching, coming to grips with the fact that we have been on a long loop through time that has brought us back almost - but not quite - to where we were."
The Sydney Morning Herald
July 18, 2005
The Palmer inquiry lays bare an inept and cruel system. David Marr reports.
Travel was once Cornelia Rau's career. Until her first serious crack-up in 1998, she was a fine Qantas air hostess. Then travel became part of her pathology: a schizophrenic woman of immense energy, on the run from her family, from mental hospitals and from Australia. She caught planes, she hitched, she took terrible risks on wild jaunts through Thailand, South America and Europe. She turned up dishevelled on the doorstep of family friends abroad; she was rescued by Australian officials in far-flung cities; more than once her parents hauled her home.
On March 17 last year, she slipped away from the psychiatric wing of Manly Hospital and stripped her account of $2000. She was off again. But within days something happened that would shape this story from beginning to end: she lost her new passport issued at the German consulate in Woollahra a few weeks earlier. To replace it would risk alerting her family and see her forced back to hospital. Somewhere on the road to far north Queensland she stole another. It was Norwegian and useless to her. By late March, Rau was trapped.
What happened next has a definite if warped logic to it: a woman turned up at Cape York in the middle of the rainy season calling herself Anna Brotmeyer or Anna Schmidt. She said she was a German backpacker who had overstayed her time in Australia. Driven eight hours down the rutted road to Cairns, she announced first to the police and then to the honorary German consul that she wanted a new passport and wanted to go home.
The 10-month saga of this woman's mistreatment at the hands of the Immigration Department is so rich in appalling detail it is easy to lose sight of the simple strategy that lay behind it all: to leave Anna behind bars, her health failing, until she revealed the details needed to issue those fresh papers. This approach was not invented for Anna. We're talking standard practice here: the recalcitrant remain locked up until they co-operate, forever if necessary.
Everything depended on the Germans. This is not just the story of how the Immigration Department failed a very ill Australian resident, Cornelia Rau. It's also the story of a clash of bureaucratic cultures: between the scrupulous Germans and their insistence on hard evidence, and the sloppy Australians who never found a shred of evidence to support the only plan they ever thought up to solve this mess: to deport to Germany the woman known as Anna. Cornelia was German, of course. Anna was not. Anna was a mad woman's delusion. Australian officials believed in her to the end.
And if the result was cruel, what does that matter? Isn't having an Immigration Department that's known to be nasty, dilatory and inflexible as much part of the deterrence system as putting the navy into the Indian Ocean and building detention prisons in the desert? Isn't this how Australia sends a message to refugees and would-be illegal immigrants across the world: don't try it on?
ANNA was flown down from Cairns by Queensland Police Air Wing on April 5 last year and taken to the Brisbane Women's prison. In his report published last week, the former commissioner of the Australian Federal Police, Mick Palmer, wrote: "She was not a prisoner, had done nothing wrong, and was put there simply for administrative convenience." Prisoners report that was Anna's mantra through the months ahead: "I have done nothing wrong."
The Immigration Department did not move swiftly. It was a couple of days before Ben Stoneley, the compliance officer responsible for liaising with detainees in prison, went out to Wacol to visit Anna. She gave him the same messy, incomplete biography she had given the police and Iris Indorato, the honorary German consul in Cairns: she was German, had grown up on a farm near Dresden but the hippie lifestyle she led as a child left her unsure of her parents' names or her own date of birth. She thought she might be 25. She claimed her lost passport was in the name Schmidt.
Immigration already knew Anna's story was fundamentally flawed. Stoneley had confirmed that none of the various permutations of names Anna had given - Schmidt, Schmitz, Brotmeyer - turned up on the department's database of movements in and out of Australia. Palmer wrote: "Australia has one of the most effective Movements databases in the world." If a name doesn't appear there, then the name is false or that person has never travelled in and out of the country.
Palmer says this should have alerted Immigration Department staff "at an early stage that there was something strange about this situation and that more thorough assessment was called for". Instead, Anna was left to come to her senses.
Stoneley waited three weeks before visiting her again. After that inconclusive meeting, he did not visit her at Wacol for another five months. This was, Palmer noted, a breach of Departmental Instruction 244 that requires case officers "to undertake monthly personal visits with detainees".
Debbie Kilroy from the prison reform group, Sisters Inside, met Anna and began to lobby Stoneley on her behalf. Anna had come to Kilroy in great distress. "I'm not supposed to be here. I don't know what's going on. I haven't done anything wrong." According to Kilroy, Stoneley explained that Anna would be held "until she gives better information on her identity". He told Kilroy they needed "honest" information.
After a month, Immigration sent Anna an application form for German papers. The Germans had already dismissed the shabby biography Anna presented up in Cairns. Now Anna made a pathetic attempt to comply with the republic's bureaucratic demands. She could not even fill in her own date of birth. The German consulate in Sydney advised Immigration not to bother lodging the application as it was so obviously incomplete.
That was in mid-May. From time to time, the immigration office in Brisbane talked about this case but essentially Anna was just left out at Wacol, parked in a women's prison. Palmer is scathing about the failure to get her out of there, to review her case, to think afresh. But the department plodded down the only course it ever chose to pursue: prove the woman German and deport her.
In mid-June, the Australian embassy in Berlin was asked to lend a hand. Diplomatic efforts to identify Anna would drag on into August. In these months of absolute inaction, Anna's behaviour deteriorated dramatically.
PRISONS everywhere face the problem of distinguishing bad behaviour from mental collapse. Anna's behaviour had been odd from the beginning. The first doctor to examine her at Wacol put this down to her being "a stranger in a strange land". By May, Anna had been two months without medication for schizophrenia and was showing distressing signs of what prison records called "unusual behaviour and poor hygiene". She paced; she stared; she hoarded food; her moods swung about; she wouldn't wash.
Was she to be treated or disciplined? A psychologist from the Prison Mental Health Service saw no evidence of mental illness and when Anna's behaviour deteriorated further in June, she began to be disciplined by being placed for days at a time in "separate confinement". She was extremely distressed.
Finally on August 10 a psychiatrist, Dr Dominique Hannah, was called in and after only a few moments with Anna realised something was badly amiss. She reported: "The behaviour of Ms Brotmeyer had been becoming increasingly bizarre and her presentation was consistent with a psychotic disorder." She recommended Anna be taken to hospital for assessment.
Ten days later Anna found herself - once again - at Brisbane's Princess Alexandra Hospital. As Cornelia Rau she had been treated there for about a month in 2002. No one recognised her now. But the grim irony was that somewhere in the hospital were already the records needed to identify this woman's profound mental problems.
Anna brought few records from prison to assist the clinicians, but she did bring two prison guards who had to remain in line of sight at all times - despite clinical staff being advised: "Ms Brotmeyer was not at risk to herself or others." Palmer believed the presence of those guards "hampered" Anna's assessment. The department's top priority, it seems, was not her health but making sure she didn't do a runner.
Prison medical staff were aghast when Anna returned on August 26 with her papers stamped: "Does not fulfil any diagnostic criteria for mental illness." Anna was soon back in confinement, again for failing to wash. Dr Hannah, due to visit her at this time, was turned away by the prison "for operational reasons". Palmer was very critical of this: "Only in the most extreme circumstances should essential medical treatment be deferred."
IMMIGRATION'S hopes of deporting Anna at any moment were now beginning to fade. From the moment of her arrival in prison in April - with her papers marked "For deportation tomorrow" - everyone seemed to assume she was going at any day. Even in August, the staff at Princess Alexandra were under the impression she would be "repatriated to Germany on discharge from the unit".
Palmer birched the Immigration Department for not correcting this misapprehension which he believed contributed to the failure of proper care for Anna.
The truth was that after holding this woman in prison for nearly six months, Immigration frankly didn't have a clue who she was or a hope in hell of deporting her. Shortly after emerging from hospital, Anna rang the German consulate in Brisbane and on September 17, Ursula Sterf and Detlef Sulzer visited her at Wacol. Nothing came of it. In Palmer's words: "She repeats her story but provides insufficient details to allow for the issuing of a German passport."
What now? Palmer is amazed that the officers dealing with Anna's case hadn't by this time begun to consider the possibility that she may be Australian. Anna sounded Australian and knew an awful lot about the country for a backpacker. But all the way to end, the Department of Immigration never focused on the possibility that the woman they had on their hands was anything but a German backpacker who had outstayed her visa.
Palmer accuses the department of rigid thinking and "an entrenched culture fixed on process and apparently oblivious to the outcomes being achieved". He points to poor sleuthing, poor records, poor case management and overwork. He was particularly scathing that the department was oblivious to the plight of an innocent woman housed for so long in a prison.
Palmer wrote: "The fact that a person's liberty had been taken seemed to be accepted simply as a 'matter of fact' and a result of the person's own doing and circumstances brought about by their actions." Under the department's own rules, prison is only ever to be "a last resort" for immigration detainees, and only used until alternative arrangements can be made. Anna had been in the Brisbane Women's prison for six months. "Had proper processes been adhered to," Palmer wrote, "she might not have been there for more than a week."
This is a country where public servants can, on their own authority, send people to prison for long periods. No magistrates, no judges. As Palmer pointed out, these are "exceptional, even extraordinary powers" and he found it a matter of great concern that immigration officers were expected to exercise them "without adequate training, without proper management and oversight, with poor information systems, and with no genuine checks and balances".
Palmer does not address a deeper scandal: that the department has been at loggerheads with the courts for years over a fundamental question. What test must officers apply when holding people in detention for any length of time?
Is it enough to "reasonably suspect" the person is unlawfully in Australia, or must officers be much, much more certain?
Immigration believes reasonable suspicion is enough. Giving evidence to a Senate estimates committee earlier this year, the Immigration Minister, Amanda Vanstone and her then department head, Bill Farmer, argued for maximum leeway in the hands of their officers. Vanstone told the senators that immigration detention is "lawful up until the time you discovered that your suspicion was incorrect".
But that is not what the courts say. In 2003, a full federal court of three judges headed by the Chief Justice of the court, Michael Black, unanimously declared that suspicion is not enough. The department must know someone is unlawfully in Australia to hold them for any length of time. But the Immigration Department continues to work on a day-to-day basis in defiance of that ruling.
In Anna's case, officers may have had reasonable grounds to suspect she was unlawfully in Australia in the very early days of the saga - though even that is open to question - but they certainly never established she actually was unlawfully in this country. It was only ever suspicion.
Palmer does not get involved in this stand-off between the department and the courts, but he hints very strongly that as the weeks went by, and absolutely nothing was discovered to sustain the department's suspicions, that Anna should have been released.
One of Palmer's principal findings is this: "Officers should not only have continued inquiries aimed at identifying Anna; they should also have continued to question whether they were still able to demonstrate that the suspicion on which the detention was originally based persisted and that it was still reasonably held."
They did not. Instead, it was decided to transfer Anna to Baxter detention centre in South Australia - not an imminent deportee now, but a long stayer.
Anna was once again in the punishment cells when her case officer, Stoneley, arrived on September 30. It was their first face-to-face meeting since May. Documents provided to the Palmer inquiry by the Queensland Government record that Anna was "teary and feeling sad because she had been in the detention unit for so long". She refused to sign the notice of intended transfer Stoneley handed her.
A few days later, Anna was restrained by prison officers and 10milligrams of the sedative diazepam was administered to her intramuscularly. Next day, another 10milligrams was administered orally and she was placed in restraints. Taken to Brisbane Airport, she was flown on commercial flights first to Adelaide and then Whyalla where a van was waiting to take her out to the camp.
The Sydney Morning Herald
July 19, 2005
One woman caught in the net illustrates how desperately the Immigration Department needs cultural change, writes David Marr.
BAXTER sits in the scrub 10 kilometres outside Port Augusta. Such a hostile, distant setting is a deliberate part of this country's deterrence policy. Having this place out in the wilds sends a message to the world - and to the electorate - that life can be very harsh if you tangle with Australia's immigration system.
Mick Palmer, in his report published last week, wrote that the facilities at Baxter are modelled on prison facilities and the operating regime is based on prison norms. Most of the guards have worked in prisons: "There is an enduring tension between containment and care, and the emphasis at Baxter is on containment."
Anna Brotmeyer - or Anna Schmidt as she sometimes called herself - was in trouble within a week of her arrival at Baxter on October 6 last year. After six months in a Brisbane prison and seven months without medication for schizophrenia, Anna paced and stared. Her moods swung erratically. She stole food. She would strip off and wander half-naked around the centre.
On October 15, she was separated from the women and families and punished by being placed in Red One compound - only it's not called punishment at Baxter but "behaviour modification".
The rackety Anna was the only one anyone at Baxter knew. "Regrettably this abnormal behaviour was treated as normal for Anna," writes Palmer. There were rumours she had lived for a time with Aborigines in the far north of Queensland. Palmer heard of guards who believed her behaviour in Baxter was consistent "with someone who had been involved with drugs or had suffered brain damage as a result of sniffing petrol".
The centre's psychologist had a more sophisticated diagnosis: he put Anna's problem down to a severe "personality disorder" which compelled her "to push the boundaries in order to draw others toward her on a constant basis".
Such disorders aren't treated but disciplined. It was the day after this assessment that Anna was taken out of the compound for women and families and placed with the other difficult cases in Red One. She would live there for all but a few days of her time in Baxter. Anna was the only woman in the compound.
After six months of inept and desultory investigation, the department still had no idea who this woman was and had found not a shred of evidence to back her story that she was a German backpacker who had overstayed her visa. She had been in Red One about a week when an immigration officer asked her directly: "Are you Australian?" Anna gave a blank stare and made no reply.
One initiative by the Immigration Department could have solved the Anna mystery at a stroke: all it had to do was publish her photograph. Palmer wrote: "The inquiry is convinced that, had Anna's photograph been more widely published early in her detention and as soon as the difficulties with identifying her were becoming apparent, she would have been identified."
NSW police had her photograph. So did the German consulate in Sydney. It hung in the foyer there throughout this saga. There were any number of Australians who would recognise this strikingly beautiful, fit young woman if her picture ever appeared in the papers. But an old taboo constrained the department - the taboo against publishing "humanising" images of detainees.
Palmer doesn't use that language. He talks of a misplaced concern for privacy and a lack "openness and transparency", which he sees as yet further evidence of the department's dysfunctional culture. Immigration would supply a picture to the NSW police in the last hours of Anna's ordeal - and that would do the trick - but this simple solution never occurred to immigration bureaucrats as the mystery of Anna deepened.
ANNA'S life in Red One was run according to "rigid, step-by-step protocols" designed in Canberra by the Immigration Department and imposed as an inflexible disciplinary regime in Baxter. The staff on the ground had long been trying to persuade Immigration to reform these rules but Palmer reports: "The speed of response from Canberra to urgent operational concerns was described as 'glacial'."
Like all cases at Baxter, Anna's was managed from far away Canberra. Her fate in Baxter was exactly as head office ordered. The management she experienced - "disjointed, fragmented and poorly co-ordinated" says Palmer - was not exceptional. A fundamental conclusion of Palmer's report is that detainees suffered "not so much incompetent management but an absence of management". No one was managing the managers. "Nobody was in charge."
Files were building up everywhere on the mysterious German woman at Baxter, but no one had a bird's eye view of the case. Palmer found record-keeping systems in the department were "seriously flawed" and it was difficult even for him to pull together all the Anna material. "Relevant documents were kept in several different locations and as both hard-copy files and computer records." As a consequence, "nobody was gathering and collating the results of individual search activities".
Palmer blames this mess for the failure, about six weeks after Anna's arrival at Baxter, to direct the search for her identity down the right track. An officer at the centre concluded "Anna was an Australian national of German parents" and he recommended the department check with missing persons and the Australian Federal Police. Palmer writes: "This was communicated to staff in Baxter and Canberra but does not seem to have prompted any action."
This was in late November and by this time Anna's behaviour had again deteriorated and she was enduring her second spell in Baxter's dreaded Management Unit. This is an inner compound of Red One that Palmer says is designed "to contain disruptive or self-harming behaviour".
The 10 rooms are bare and under continuous video surveillance with a minimum of privacy. Palmer found "no evidence of improper behaviour by detention officers" towards Anna while she was in the Management Unit. Yet he is far from convinced such a unit is appropriate for immigration detainees: "It is difficult in this environment to demonstrate that the purpose is not punitive."
ANNA announced she was desperate to spend a white Christmas at home in Dresden. An immigration officer came to help her fill in yet another application for a German passport. But it was the same story as before. A departmental chronology given to Senator Joe Ludwig records: "The application was not submitted to the German authorities as Anna Brotmeyer aka Schmidt stated she could not provide any documents of identification."
She had no documents, several dates of birth, no names for her parents, no coherent account of her upbringing or how she arrived in Australia and not a single soul in Germany who could vouch for her - yet the Immigration Department was convinced she was a German tourist.
By early December, the German consulate in Melbourne was co-ordinating fresh inquiries in Germany. Consulate staff wanted fingerprints. Anna refused. They wanted a photograph and the department provided one. As the Germans reported failure after failure through December and January, the Immigration Department kept urging them to try again. After a phone call to the consulate from Anna, the vice-consul rang her case officer to say: "Anna might be an Australian citizen of German parents." The clue was ignored.
While immigration officers inquired of government departments around Australia - including some missing persons databases - Australian diplomats had been put on the job of trying to track down likely Schmidts and Brotmeyers in Warsaw, Moscow, Kiev and Prague. All these inquiries failed.
In late January, the Germans finally dug in their heels, telling the department: "Our hands are tied, since by international law the German consulate-general in Melbourne has no authority any more to continue activities in this matter." But they saw bigger issues looming here.
For almost two months refugee advocates had been ringing the consulate to lobby on behalf of the mad "German" in Baxter who was receiving no medical treatment. The then ambassador, Dr Klaus-Peter Klaiber, told the Herald these complaints were taken seriously. "The NGOs claimed there were human right issues at stake and we informed [the Immigration Department] accordingly."
PUTTING jails in remote places has always made citizens feel safer. But the drawbacks are so brutal for prisoners and their guards that after a couple of centuries of debate it's now widely agreed that the best place for prisons is in cities. That was not the thinking behind Baxter. This was an old-fashioned exercise in deterrence by geography. Detainees might not like it but most Australians do.
Yet the drawbacks remain. Palmer notes that unlike Villawood in Sydney and Maribyrnong in Melbourne, "Baxter does not have immediate access to 'big city' services. Port Augusta has 15,000 inhabitants; Adelaide is 300 kilometres away."
Port Augusta has no psychiatrist.
Palmer was extremely critical of arrangements for providing medical services to detainees. He found the contract between the department and the company that manages the centre - Global Solutions Limited Australia, known as GSL - failed to set "measurable standards".
Further confusing the situation were GSL's arrangements with local GPs, the South Australian Rural and Remote Mental Health Service - and a consulting psychiatrist, Dr Andrew Frukacz, who flew from NSW every month or so to visit Baxter.
Messy as all that is, Palmer was adamant that ultimate responsibility for the health of the detainees remained where it always had - with the Department of Immigration.
Frukacz saw Anna a month after her arrival in Baxter. He sensed immediately what might be wrong. "Diagnosis unclear but possibilities include: 1. Schizophrenia 2. Personality disorder. Her posturings, bizarre behaviours and guardedness lead me to consider schizophrenia." He recommended she be taken to Glenside Psychiatric Hospital in Adelaide to be assessed. He did not commit her nor did he speak directly with psychiatrists there. Frukacz flew out and did not see Anna again.
As her behaviour deteriorated in the months ahead the staff at Baxter negotiated in a leisurely fashion with the staff at Glenside to get her to Adelaide.
Palmer admits to being unable to decide between "the differing perspectives" of the two sides. But what he called "the clinical pathways" were clearly not working here. "The situation is typical of the lack of leadership and acceptance of responsibility the inquiry found on a number of occasions."
Anna was refusing to co-operate. She would have to be detained under the South Australian Mental Health Act to be taken to Adelaide. The pressure on Glenside was already acute. As Palmer remarks, patients from Baxter brought with them "the disruptive presence on the ward of escorting officers" and these patients tended to be very sick and stay a long time. Two arrived at the end of December which set back Anna's chances. Palmer wrote: "Staff at Glenside had a preference that only one Baxter patient should be admitted at a time."
All the way through January, doctors talked to one another but Anna stayed exactly where she was in Red One. "Everyone saw themselves as 'only a bit player'; no one was managing the process," writes Palmer. "The defined clinical pathways did not work effectively. The 'system' failed. As far as delivering quality care is concerned, her identity and immigration status would have been irrelevant. She was simply a person who needed help." Palmer would conclude: "The mental health care delivered at Baxter is inadequate by any standards."
Now three months without seeing a psychiatrist and nearly 10 months without medication, she was sicker than ever - withdrawn, often screaming, stripping off clothes, laughing hysterically, sometimes just staring for hours. She would make strange, almost silent phone calls to say: "This is not a nice place."
DESPITE having no power and little time, Mick Palmer and his team have produced a report which could change the face of immigration detention. But there are gaps. The worst is his failure to address the culpability of Amanda Vanstone and her office. This was her department. She sat above this culture. She was not questioned. This is a report written for her, not about her.
And her office was directly involved in the scandal, certainly for the last month of Anna's torture in Baxter. Vanstone told Senate estimates earlier this year: "It was early in January that my office was first made aware of this case."
The same refugee advocates lobbying the German consulate were also lobbying her office. Whether they had an impact, Palmer doesn't report but he credits them with generating the "advocacy driven publicity" that finally succeeded where the department's worldwide searches had failed.
It was so simple in the end. On February 3, Edgar and Veronika Rau read a story in this paper about a mysterious "Anna" at Baxter who might be German and clearly needed psychiatric care. They guessed this was their daughter. They alerted the police, who asked Baxter for a photograph. It was Cornelia. By chance the medicos had finally got their act together that afternoon and were about to remove Cornelia to Adelaide. By the time she was ambushed under the showers that evening, she was no longer a detainee. Police and ambulance officers took her about 11 pm to Port Augusta hospital. Next day she was in Glenside.
Since the publication of Palmer's report, attempts have been made to blame the scandal he has uncovered - not just the scandal of Cornelia Rau but also the deportation of Vivian Alvarez Solon and the 200 further cases of possible wrongful detention yet to be investigated by the Ombudsman - on the lower rungs of the Immigration Department.
This is emphatically not Palmer's verdict. He calls this a "strongly hierarchical" department with "a high degree of vertical control" and the rigid culture of habit, denial and self-justification he uncovered was not "confined to operational levels but were pervasive at senior executive management level". He sheets responsibility home to the very top.
Such organisations do not grow by accident. By and large Australians have been happy with this cruel and dysfunctional department guarding our borders. It's a system that's developed under two governments. For Howard, in particular, it's been a winner - until it swept into its maw Rau. She was not an Afghan or a Thai sex slave. She was one of us.
Perhaps Vanstone and Howard are sincere when they say they accept "the thrust" of Palmer recommendations for root and branch reform. Perhaps. No minister or bureaucrat has suffered because of Palmer's revelations. And Howard, who reads this country so well, must wonder if Australia is ready, even now, for an immigration system with a human face.
Processes failed. It was not a failure of instructions ... the instructions were not followed. It was a serious failure of management process and corporate oversight.
Everyone saw themselves as "only a bit player"; no one was managing the process. The defined clinical pathways did not work effectively. The "system" failed Cornelia Rau. The mental health care delivered at Baxter is inadequate by any standards.
A culture that ignores criticism and is unduly defensive, process motivated and unwilling to question itself. Reform must come from the top. Executive management must demonstrate consistent commitment to establishing new values and perspectives. These will guide the new way of doing business.