Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697643144750.pdf (Australia)
24 February 2016 Ms Toni Matulick Committee Secretary Senate Legal and Constitutional Affairs Committee PO Box 6100 Parliament House Canberra, ACT, 2600 Email: legcon.sen@aph.gov.au Dear Members of the Select Committee RE: Response to Doctors for Refugees Submission to the Select Committee International Health and Medical Services (IHMS) welcomes the opportunity to provide a response to the written submission made by Doctors for Refugees.
Background IHMS is contracted by the Commonwealth of Australia, represented by the Department of Immigration and Border Protection (the Department), to provide primary and mental health care services to asylum seekers and refugees residing within the Regional Processing Centres (RPC) on Nauru and Manus Island.
The IHMS contracts with the Department also allow primary and mental health services to be provided to refugees living in the Nauru community, and IHMS is also contracted to provide limited primary health and mental health services in Papua New Guinea at the East Lorengau Refugee Transit Centre (ELRTC).

Refugees in Nauru and Manus also have the option of attending the local health services should they prefer.
General practitioner, nursing and mental health care clinics are open at both RPCs seven days a week.

There is also after-hours medical staffing to respond to any after-hours RPC medical emergencies.

The primary health clinical team in Nauru is augmented by obstetricians, midwives and medical officers with pediatric training.

Additional health services for refugees in Nauru, such as emergency, specialist and allied health care is provided by the Republic of Nauru Hospital (RoNH) and not by IHMS.
To supplement the on-site primary health care service to Asylum Seekers and Refugees at the RPCs, IHMS provides specialist services via visiting medical specialists, tele-health consultations with specialists based in Australia, second opinions from specialists based in Australia who review clinical records, and referral for specialist opinions at Pacific International Hospital (PIH) in Port Moresby in line with Australian Government policy.
In addition to providing first-line health care, IHMS also undertakes health-promotion and disease-prevention activities, assisting people with chronic conditions to manage their own health.

IHMS provides a comprehensive vector control program at the Manus Island RPC and ELRTC which aims to control the risks associated with mosquito transmitted diseases.

24/11/2016 Letter to Senate Select Committee responding to Doctors for Refugees Submission All rights reserved.
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Page 1 of 6 Serious allegations of abuse, self-harm and neglect of asylum seekers in relation to the Nauru Regional ProcessingCentre, and any like allegations in relation to the Manus Regional Processing CentreSubmission 56 - IHMS Response Since 2003 when IHMS first began providing services to people in immigration detention and then to asylum seekers and refugees on Manus Island and Nauru, we have developed robust systems to assure high standards of care for all of our patients, in full compliance with international healthcare standards and regulations.
As evidenced by our frequent dialogue with Doctors for Refugees and other advocacy groups and stakeholders, IHMS welcomes external comment and review as a means to continuously improve and adapt the service we provide in these challenging environments.

IHMS is a medically-led health services provider.

Unlike Doctors for Refugees, we are not politically or ideologically motivated.

We believe that refugees and asylum seekers, as with all patients, have the right to high quality health care.
Medical professionals across the globe and of all political persuasions treat victims of armed conflict, terrorism, natural or man-made disasters, famine, or those incarcerated in prisons, regardless of whether or not they support the policies or practices of the responsible government.

IHMS medical professionals operate within a very robust clinical governance system with a mission to deliver high quality, medically appropriate healthcare with humanity and cultural sensitivity.
Access to medical records IHMS refutes the assertion that it does not provide medical records to Doctors for Refugees.

As a function of its role providing primary and mental health care to people in Australian immigration detention and asylum seekers and refugees in PNG and Nauru, IHMS is in possession of a significant number of medical records that contain sensitive information on IHMS’ patients.
In being the steward of this personal information, IHMS recognises that it owes its patients a duty of confidentiality.

IHMS takes this duty very seriously.

IHMS receives approximately 70 requests per month for third party access to medical records.

When IHMS declines a third party request for access to a patient’s medical records it does so solely on the basis that positive identification of the person’s informed consent to such access has not been met.
IHMS has been in a position in the past where certain organisations have fraudulently attempted to access personal information: it was solely as a result of IHMS’ scrutiny that access was denied.

To this end, when IHMS declines access to Doctors for Refugees it does so for a genuine reason.
It should also be noted that all complaints referred to the Office of the Australian Information Commissioner (OAIC) by Doctors for Refugees in relation to IHMS and the provision of medical records have been found in IHMS’ favour.
As a result of the large number of legally invalid consent forms we were receiving from Doctors for Refugees, IHMS requested a meeting with the OAIC, the Department and Doctors for Refugees to discuss how to best 24/02/2017 Letter to Senate Select Committee responding to Doctors for Refugees Submission All rights reserved.

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Page 2 of 6 Serious allegations of abuse, self-harm and neglect of asylum seekers in relation to the Nauru Regional ProcessingCentre, and any like allegations in relation to the Manus Regional Processing CentreSubmission 56 - IHMS Response resolve this issue.

This meeting was held on the 8th of November 2016 at the offices of the OAIC.

At this meeting we agreed on a new process to facilitate third party requests for medical records.
IHMS subsequently drafted a new consent form allowing for positive identification of the patient to be made by an IHMS clinician.

This new process has been implemented and is set out on the IHMS website www.ihms.com.au under the tab ‘Record Requests’.

Response to medical recommendations from Doctors for Refugees IHMS medical directors often receive correspondence from Doctors for Refugees containing medical recommendations with regard to particular cases.
We have requested in the past that these communications be sent to one single point in IHMS rather than to multiple addressees across both IHMS and the Department in order that a response can be coordinated.

This request has been ignored.

Where required, IHMS responds in detail to Doctors for Refugees recommendations, and we can provide many examples of this if requested.

However it should be noted that IHMS has its own extensive specialist referral network, as does the Department.
On many occasions the cases being reviewed by Doctors for Refugees have also been reviewed by these specialists and recommendations supplied.

We have previously informed Doctors for Refugees that if they do not receive a response, or only receive an acknowledgement, their recommendations have not been ignored; they have passed to the relevant Medical Director who has considered them together with all the other specialist reviews and recommendations pertaining to the particular case.
Obstruction of clinical decisions IHMS often has robust discussions with the Department in respect to its clinical recommendations.

The appointment by the Department of a Chief Medical Officer (Department of Immigration and Border Protection) /Surgeon-General (Australian Border Force) has assisted in ensuring that these discussions take place between clinicians.
IHMS understands that it does not hold exclusivity with regards to the provision of health care to asylum seekers and refugees and that the Department may contract other health providers to provide services to asylum seekers and refugees.

Likewise, the Department may seek external review of IHMS recommendations and has reserved the right to act on the recommendations of a third-party rather than that of IHMS.
In such cases, IHMS relinquishes the responsibility for care and hands over that responsibility to the third party provider in accordance with the wishes of the Department.

Process for notification of self-harm In conjunction with other stakeholders, IHMS has embraced the Supportive Monitoring and Engagement (SME) program.

This program is designed to assist in the management of self-harm and suicide risk.
IHMS takes self harm and indeed all mental health issues for people in our care very seriously, and we work with the Department on complex cases, quality and safety, and implementing and maintaining quality and safety systems and processes.

24/02/2017 Letter to Senate Select Committee responding to Doctors for Refugees Submission All rights reserved.

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Page 3 of 6 Serious allegations of abuse, self-harm and neglect of asylum seekers in relation to the Nauru Regional ProcessingCentre, and any like allegations in relation to the Manus Regional Processing CentreSubmission 56 - IHMS Response The Department has an internal incident reporting tool which receives incident reports from all service providers including IHMS.
IHMS incident reporting to the Department includes incidents of threatened or actual self-harm reported by clinical staff, along with multiple other ‘mandatory incident reporting’ items.

With the majority of Nauru refugees now living in the community, and some refugees on Manus living in East Lorengau, IHMS will only be aware of self-harm incidents in which the refugee or asylum seeker presents or is presented for IHMS clinical intervention.
Where this occurs, an incident report is completed, a mental health evaluation is undertaken and the self-harm incident is included within the medical record together with the details of medical follow up.

Mandatory reporting requirements IHMS complies with all mandatory reporting requirements.

These are set out in the Department’s submission to the Inquiry.
In the event of an alleged sexual assault of a minor, or an event that may otherwise be a child protection matter, the IHMS medical and mental health teams may become involved if there is a request for support, or if there are mental health issues either preceding the notification or subsequent to it.

IHMS is able to and does provide psychological input as needed in these cases.
RoNH and PIH There appears to be considerable confusion within Doctors for Refugees over what IHMS is contracted to provide and what is provided by the RoNH and the Pacific International Hospital (PIH) in Port Moresby.

IHMS is contracted to provide primary health care services and mental health support to both asylum seekers and refugees.
Nauru In Nauru, additional health services for refugees in Nauru, such as emergency, specialist and allied health care are provided by the Republic of Nauru Hospital (RoNH) and not by IHMS.

Where appropriate these may also be utilised by asylum seekers.

The RoNH is a public hospital run by the Government of Nauru.

The RoNH is staffed by RoNH employees, not IHMS employees, and IHMS is not involved in the administration of the RoNH in any way.

As such IHMS does not have access to its medical records.
If IHMS is of the opinion that an asylum seeker residing at the RPC in Nauru requires specialist care which cannot be provided on Nauru or via telehealth consultation, IHMS will recommend transfer for specialist medical care and submit a Request for Medical Movement (RMM) to the Department.
Previously, PIH in Port Moresby was considered as a provider of specialist services (in line with Government policy) and, subject to the standard of that care being consistent with the standard available in the Australian community, IHMS would seek Departmental approval via a Request for Medical Movement (RMM) to refer the patient to PIH.

However, due to PNG Visa restrictions, this option is currently not available and all RMMs relating to asylum seekers on Nauru cite Australia as the destination.
The Department is then responsible for granting approval of the RMM and facilitating transfer as 24/02/2017 Letter to Senate Select Committee responding to Doctors for Refugees Submission All rights reserved.

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Page 4 of 6 Serious allegations of abuse, self-harm and neglect of asylum seekers in relation to the Nauru Regional ProcessingCentre, and any like allegations in relation to the Manus Regional Processing CentreSubmission 56 - IHMS Response recommended.
For refugees residing in the Nauruan community or at the RPC, the RoNH follows a process called the Overseas Medical Referral (OMR) process.

A patient (Nauruan national or refugee) is referred to the OMR Committee by a RoNH doctor and the Committee makes a decision as to whether the patient will see a specialist at the RoNH or be transferred to a third country for treatment.

IHMS is not involved in this process.


Manus In Manus, IHMS follows a similar process in relation to RMMs for asylum seekers and refugees residing at the RPC, however PIH in Port Moresby remains a referral option.

With knowledge of available services and standards at PIH, IHMS makes a clinical assessment as to whether the required specialist service can be provided at PIH and completes the RMM accordingly.
Whether they can be provided at PIH requires an understanding of the available clinicians including their skills together with available equipment and ancillary services.

IHMS clinicians can only refer to PIH when it is clinically appropriate i.e.

when the clinical services are available at PIH and are capable of being provided at an Australian standard.
In the event that the clinical assessment cannot verify that an Australian standard of care will be available to the patient, or that there is insufficient information made available to IHMS concerning the care available at PIH, then the RMM submitted by IHMS will recommend referral to another facility where the Australian standard of care is available.

Once the RMM is approved, IHMS assists with the coordination of the transfer.
As noted above, in referring a client for specialist care, IHMS may determine that the relevant clinical service or relevant standard of clinical service is not available or not of a suitable standard at PIH and, as a consequence, refer the client to an appropriate provider in Australia (or third country).

If the Department then chooses to transfer a client to PIH, IHMS will relinquish the responsibility for care and hand over that responsibility to PIH in accordance with the wishes of the Department.
IHMS does not have a “clinic” in Port Moresby but provides a nurse liaison service - the nurse liaison service facilitates appointments with specialists, pathology or medical imaging and receives reports from the specialist providers so that appropriate follow-up can be arranged.

The nurse liaison team will also assist in the provision of routine medications.
IHMS does not have a doctor based in Port Moresby and cannot provide comprehensive medical assessments of clients transferred to Port Moresby for specialist care.

PIH is an independent private hospital and IHMS has no control over their services and no access to their medical records.

With respect to PNG refugees residing outside of the Manus RPC, including those refugees residing at East Lorengau, all emergency and specialist services are provided through the PNG public health system.
Part Six of the Australian Border Force Act 2015 IHMS clinicians are not subject to the ABF Act, including its secrecy and disclosure provisions.

IHMS 24/02/2017 Letter to Senate Select Committee responding to Doctors for Refugees Submission All rights reserved.

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Page 5 of 6 Serious allegations of abuse, self-harm and neglect of asylum seekers in relation to the Nauru Regional ProcessingCentre, and any like allegations in relation to the Manus Regional Processing CentreSubmission 56 - IHMS Response promotes a culture of integrity, honesty and ethical behaviour and all staff are encouraged to raise any concerns they may have through appropriate internal channels.
To assist staff who want to report anonymously, IHMS uses the Integrity Reports application which allows seamless anonymous communication between staff and a designated investigator.

Communication conducted through this application is protected as is the employee’s identity.

All IHMS staff are required to fulfil their mandatory reporting obligations, including in relation to child abuse, self-harm and neglect.
Allegation of secrecy and obstruction IHMS strongly refutes the allegation by Doctors for Refugees that IHMS has constructed a wall of secrecy and obstruction amounting to obscene negligence.
Despite the fact that, of its own admission, Doctors for Refugees is a politically-inspired advocacy group, IHMS has elected to recognise the health advocacy of the group and has proactively pursued a relationship of transparent engagement with Doctors for Refugees, at all times engaging professionally with representatives from Doctors for Refugees.
Doctors for Refugees is just one of the very many stakeholders IHMS works with on a daily basis and we are proud of our open and transparent engagement with all of these stakeholders.

Yours sincerely Damien Johnston Chief Operating Officer Dr Kalesh Seevnarain Senior Medical Director 24/02/2017 Letter to Senate Select Committee responding to Doctors for Refugees Submission All rights reserved.

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Page 6 of 6 Serious allegations of abuse, self-harm and neglect of asylum seekers in relation to the Nauru Regional ProcessingCentre, and any like allegations in relation to the Manus Regional Processing CentreSubmission 56 - IHMS Response