AT 11.47pm on March 30, 2001, an ambulance was called to a park in the northern NSW town of Lismore where Vivian Alvarez Solon, suffering from head injuries, was sitting beside a large open concrete drain.
Clothes wet, right cheek swelling, chin cut, she had trouble moving her legs. Later speculation suggested she had been in a car accident or been assaulted, but she'd probably just fallen into the drain.
Taken to the Lismore hospital, she was abusive and combative, and was soon put into the psychiatric unit. A social worker there advised Immigration's Southport office that a Filipino named Vivian Alvarez had been found wandering and might be an illegal immigrant.
That fateful call began the Kafka-like nightmare, laid bare in yesterday's Comrie report, of Australian citizen Vivian Alvarez Solon, born in the Philippines and former wife of an Australian, Robert Young.
Immigration officers interviewed Ms Alvarez Solon on May 3. Assuming she was an illegal, Immigration failed to do proper checks. One officer thought she was a sex slave; this "erroneous assumption appears to have influenced the way in which her case was handled", Mr Comrie found.
On July 12 Immigration officers collected her from the rehabilitation unit; next day she told Immigration she was an Australian citizen and wanted to stay here. But arrangements for her removal proceeded apace, despite her being disabled enough to need help with dressing and hygiene.
An undated, unsigned handwritten note placed in the Alvarez file said: "Smuggled into Australia as a sex slave. Wants to return to the Philippines. Has been physically abused."
On July 17 Queensland police entered the story, reporting her as a missing person several months after she had failed to collect her son from childcare in Brisbane.
A Philippines consular representative and members of the Philippine community visited her on July 18-19 at the Brisbane motel where she was detained. She told a Filipino social worker she'd been married to a Mr Young, but the information wasn't passed to Immigration.
After the Philippine embassy, which was deeply concerned she wasn't well enough to travel, refused to issue a travel document, Immigration took the "inappropriate" course of bringing in a locum to certify she was "medically fit will not be a problem on airplane". So on July 20 she was bundled onto a Qantas plane, escorted by a policewoman. At Manila she ended up with Qantas ground staff; she was taken to the Overseas Workers Welfare Association and eventually to a Catholic hospice.
Fast-forward to mid-July 2003. Queensland Missing Persons contacted Immigration asking about Vivian Solon. Immigration officers D and E did searches  the link was made between Vivian Alvarez and Vivian Solon Young. Both told the same supervisor, officer A, that an Australian citizen had been unlawfully removed. The supervisor did nothing.
After the TV program Without a Trace included Ms Alvarez Solon's photo on August 20, 2003, officer E again informed A of the mistake. Once more, A failed to act.
Officer F, in Brisbane, who had been involved in the removal, also saw the program, printed out material and took it to officer B, who had been her supervisor when Ms Alvarez Solon was removed. He did nothing.
Officer E informed the Missing Persons Bureau Ms Alvarez Solon had been removed in 2001; in early September the bureau was asking Foreign Affairs for help to search for her in the Philippines. The department provided information but didn't bother to check how an Australian citizen had come to be removed.
Robert Young, indefatigable in his search for Ms Alvarez Solon, had found out from Missing Persons that she had been sent to the Philippines. He called Immigration's contact centre in Sydney with useful information. It wasn't adequately followed up.
Spurred by Mr Young's persistence in 2004, Missing Persons contacted the supervisor of Immigration's entry systems and movements alert office in Canberra  officer A, the one who'd had been told on July 14 and August 21, 2003, of Ms Alvarez Solon's wrongful removal. A contacted the Brisbane office.
"Inquiries by staff at the Brisbane office established that Vivian Alvarez was an Australian citizen when she was removed in 2001. Two senior officers and other more junior staff in the Brisbane office were aware of these facts," the report says.
None of the three senior officers who learnt of the mistake (one in Canberra, two in Brisbane) did anything to either rectify the mistake or inform the secretary of the department or the Minister's office.
In Canberra Ms Alvarez Solon's file was kept separately from the normal files. It was found in April this year "in the desk hutch of DIMIA officer H, a subordinate of officer A".
There are many villains in Ms Alvarez Solon's sad story  and one clear hero. Her former husband never gave up in his quest to find her.
"Vivian's unlawful removal in 2001 was eventually acknowledged officially only because of the continued inquiries by Robert Young, who brought the matter to the attention of the Minister's office in an email of 4 April 2005," the report says.
"Had Mr Young not persisted, the wrong done to Vivian and DIMIA's failures in the management of her case  including the failures of three senior officers  might well have remained unknown to the Australian community."
A system riddled with flaws
The unlawful removal of Vivian Alvarez Solon was a consequence of systemic failures in the Immigration Department including inadequate training programs, database and operating system failures, poor case management and a flawed culture.
THE GOVERNMENT'S
RESPONSE
$50.3 million College of Immigration, Border Security and Compliance to train staff and enhance leadership skills for middle-ranking and senior staff.
FINDING
Alvarez Solon's serious physical and mental health problems received insufficient attention.
RESPONSE
$17.9 million on improved immigration detention health services; referral for alternative detention; and improved mental health services at Baxter.
FINDING
The chance to find Alvarez Solon was lost because of the limited ability to connect names using Immigration Department databases.
RESPONSE
Introduce a single-entry client search facility for all Immigration Department IT systems.
FINDING
Case management was catastrophic, beginning with the assumption Alvarez Solon was a sex slave.
RESPONSE
Establish a quality assurance and monitoring unit in the national immigration office, with additional funding to the Commonwealth Ombudsman.
FINDING
The fact that in 2003 and 2004 senior DIMIA officials knew an Australian citizen had been removed in 2001 but failed to act is inexcusable.
RESPONSE
A public service investigation will be held into the conduct of the officers, who could face the sack.
An independent investigation, headed by former Victorian Police Commissioner Neil Comrie, has revealed that Australian immigration department officials wrongfully deported the Australian citizen Vivian Solon to the Philippines. Ms Solon was deported in March 2001, after falling under suspicion as an illegal immigrant while she was in hospital after an accident. She was still in poor health when she was deported, and her five year old son was left behind in foster care. The mistake was not officially recognised until April 2005.

Senior officials knew of the mistake in July 2003, but neglected to correct it. In the end, it was only through the efforts of her former husband, Robert Young, who persistently pursued her case that it was eventually acted on. Some senior officials are being investigated on this issue, however, the ministers responsible for the Department -- now Amanda Vanstone, but prior to October 2003 it was Phillip Ruddock -- denied any responsibility. When asked if he felt any responsibility Mr Ruddock answered "No, none at all."

This incident is one of a number of immigration controversies that have occurred in Australia. Cornelia Rau, an Australian citizen, was accidentally imprisoned in a detention centre when the immigration department suspected her of being an illegal immigrant. The report indicates that 20 other Australian citizens have also been unjustly imprisoned by the immigration department.