The long-awaited review into the February violence, conducted by former public servant Robert Cornall, brought together more than 300 accounts and included 13 recommendations.
It found there was no particular factor that caused the February violence that resulted in at least 69 people treated for injuries.
But it says frustration and anxiety over a lack of information was a key contributor to the tensions.
The report stated G4S had been monitoring increasing tension in the centre, reaching a “flashpoint” following a meeting between community leaders and PNG and Australian Immigration officials on February 16.
During the violent protests that followed, fences were pushed over and Papua New Guinea nationals gained access to the compound.
“The nationals and sometimes expats and police went into bedrooms in Mike and dragged transferees outside to be beaten,” the report read.
“Some transferees reported that they bought immunity from bashing with cigarettes.”
It stated that Mr Berati “suffered a severe brain injury caused by a brutal beating” led by an identified PNG national employed by the Salvation Army and died several hours later.
A witness to his death said after the violence broke out, Mr Berati had tried to flee to his room and was followed by a PNG national employed by the Salvation Army.
“He hit him twice with a very long stick,” the witness said.
“… When we was trying to come upstairs he further fell down. When he fall down, more than 10 officer (sic) passed him and all of them, they kicked him in the head.”
The witness said the officials included PNG locals, guards and Australian expats.
“The last one, one of the PNG locals [redacted], the man, [redacted], he put a very big stone at his head,” he said.
A report from a medical officer said Mr Berati’s head was “shattered” by a crack in his skull.
“He would not have survived this injury even if it had occurred in, say, Sydney,” it read.
Another man lost an eye, while another had his throat cut.
The report also detailed events leading up to the riots, which it attributed in part to growing frustration over the delay in processing refugee status determinations, anger over “uncertainty about their future” and anger at being brought to PNG.
G4S also estimated that only 400, or 30 per cent, of transferees took part in riots.
Immigration Minister Scott Morrison released the report on Monday afternoon, saying the government had accepted all 13 of the report’s recommendations.
Recommendations
- That all information gathered for report be provided to Royal Papua New Guinea Constabulary to support further investigations.
- That all feedback and medical interviews with detainees be provided to Transfield staff to support welfare management.
- Implement “as quickly as possible” current measures and further initiatives to expedite the finalisation of PNG refugee status determinations and resettlement and removal processes.
- That the Government of Papua New Guinea be requested to enact similar statutory powers for the garrison and security provider as presently exist in Australia.
- That Transfield Services (and Wilson Security), the Royal Papua New Guinea Constabulary provincial police and the mobile squad clearly establish and understand their respective roles and responsibilities in regards to maintaining law and order within the Manus Island Processing Centre
- That the Department review risk involved in the conduct of the the Manus Island Processing Centre
- That the Department encourage initiatives by Transfield Services to maximise the opportunity offered by the change of service providers to restore trust and cooperation with transferees
- That Transfield Services “deal appropriately” with employees, if any, identified as assaulting transferees. This may include dismissal.
- That the Department and Transfield Services improve communication with transferees.
- That the Department put in place a comprehensive and continuing community liaison program to inform PNG locals.
- That Transfield consider recommendations and implement those improvements regarding welfare of transferees
- That Transfield assist transferees to replace personal items lost or stolen during the incidents
- That Transfield implement a comprehensive and ongoing training program for PNG staff to develop their professional skills
Mr Morrison told media that the incident was anticipated.
"There were actions taken over many months to mitigate events of this nature," he said.
He further described the riots as a "terrible, tragic and distressing sequence of events".
