A New South Wales coroner has referred the death of a Filipino migrant worker, who died after jumping from a moving vehicle in 2019, to the Australian federal police to consider further investigations.

NSW deputy state coroner Rebecca Hosking handed down the findings into the death of 21-year-old Jerwin Royupa on Friday. She concluded Royupa, a trainee at a winery, was “exploited” and exposed to “potentially criminal” conduct during his five weeks in Australia.

Royupa died in March 2019 after “voluntarily” jumping or falling from a van driven by his training scheme sponsor, who cannot be named due to legal reasons, the coroner said. In the days before his death, Royupa became “increasingly fearful” of his visa sponsor, Hosking found.

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On 14 March 2019, Royupa voluntarily exited the van being driven by his sponsor after the man threatened to take him to the airport or police.

While Royupa lay unconscious on the side of the road, the sponsor failed to immediately call an ambulance, disparaged him to a paramedic and left the scene after being told not to.

Hosking described the training sponsor’s conduct as “deplorable”.

Royupa died the following day at the Royal Melbourne hospital from complications of “multiple blunt force injuries”, Hosking said.

Hosking said she could not conclude the precise reason why Royupa left the vehicle but could not rule out there was some threat.

The training sponsor understood that if Royupa absconded he would be liable for costs associated with the worker’s recovery, the coroner said. While living at the winery where he worked, Royupa did not have access to his passport, Hosking found.

Royupa, a Filipino national who had studied agriculture, moved to Australia five weeks before his death. He arrived on a temporary subclass 407 visa, designed for workplace-based occupational training.

But the coroner found Royupa was “exclusively” performing manual labour and was not engaged in any educational training, contrary to what had been proposed to him.

The 21-year-old worker was required to work “excessive” hours – up to 60 a week – which was at odds with the “training schedule” that had been proposed, Hosking said.

He was required to work outside in excessive heat with no appropriate clothing or sun protection.

He was promised a “generous allowance” – which Hosking said was “wholly inadequate”. But no payments were made to him during his time in Australia, because the sponsor told Royupa the salary would be paid after six months.

Royupa’s proposed remuneration was a monthly base salary of $134.92, despite working 10 hours a day for six days a week, the inquest heard.

Hosking accepted the Department of Home Affairs view that it was “inappropriate” to approve the training visa, as the same documentation provided by the sponsor in a separate nomination after Royupa’s death was rejected. The decision maker for the second nomination said they were not satisfied a “genuine” training opportunity was intended.

The three-day inquest, held in December 2024, was the first in Australia to examine concerns of forced labour since modern slavery offences were criminalised through standalone offences in 2013.

Hosking made six recommendations, including that the coronial brief of evidence and transcript from hearings be referred to the AFP for consideration of further investigations.

She recommended the home affairs minister conduct an internal review to identify potential “lessons learned” and consider the need for a formal review to investigate the department’s role in approving 407 training visas that may have been used for exploitation of visa-holders.

Hosking’s other recommendations included that the NSW police commissioner liaise with the state’s anti-slavery commissioner to develop and implement mandatory modern slavery training for officers working in high-risk areas such as regional parts of the state.

A spokesperson said the Department of Home Affairs had provided full assistance to the inquest and was carefully reviewing the findings and recommendations.

“The department expresses our condolences to the family and friends of Mr Royupa,” the spokesperson said.

“The department is working on strengthened regulations for the training visa to protect visa-holders and will incorporate the coroner’s findings in this work.”

The department “applies close scrutiny” to all applications in the subclass 407 visa category, with refusal rates for 2025-26 now sitting at 45%, the spokesperson said.

NSW Police was contacted for comment.