ro Pomme f mE EE ‘Subject: RE: From the SMO Nauru ref clinical concerns. ‘Thanks for your letter regarding your concerns relating to clinical care of refugees on Nauru. Fistly, you are certainly ‘not alone in your concerns and I have raised these issues with ABF (including John Brayley) on 2 number of occasions - without a satisfactory response, | might add, tis most unfortunate that IHMS and its clinical staff have been caught in the middle of aloft. In order to understand how this has come about, one needs an explanation of the background, of which you may already be aware. lis were contracted to provide primary care services, mental health support and emergency response services to ‘transferees at the Nauru RPC. in order to facilitate specialist consultations and management when required, there were arrangements to have visiting specialists, telehealth consultations and referrals offshore, if required {and this certainly did happen previously). Originally, with regards to pregnant women, we provided antenatal care on Nauru up to 28 ‘weeks when pregnant women were referred to Australia for the final antenatal care and birthing. | think we know the limitations of the RON hospital and so, if we were to provide “Australian” standard of care, we could not refer patients to the RON hospital. As you know, over the past two years, ABF has put extreme limitations on the types of patients that ‘we can referral offshore - it does not stop us requesting these transfers but, as we are not in control of that aspect of ‘things, the patients are entirely at the mercy of the decisions made by ABF as regards transfers. You have mentioned the issue of asylum seekers not being able to go to Port Moresby because of these issues and, recently, we have requested that the ABF transfer these patients to Australia for medical care - we are awaiting approval. ‘The refugee situation is somewhat different. The original concept from the Australian and Nauru governments was that, When transferees were given refugee status, they would be incorporated into the general Nauru community just as ‘somebody who is given refugee status in Australia would be incorporated into the Australian community, As part of that incorporation into the Nauruan community, they would access health services in the same way native Nauruans would access these services, The settlement clinic was set up to provide a bridge between the RPC services and the local Nauruan health services and was only meant to provide medical care to refugees during their initial phases as a refugee {6 to 8 weeks). Consequently, the contractual arrangements that IHMS has in relation to the settlement clinic refers to “local Nauruan standards”, The reason for paper records was that this was local Nauruan standards and after the refugees had gone past their initial phase of attending the settlement clini, these records would be incorporated into the Ron hospital record. However, this transition of refugees into the local community has, on the whole, not occurred ‘for reasons which were easily predictable (but ignored in intial planning by Nauruan and Australian governments) and Certainly outside the control of IHMS. So, as @ result, the contractual arrangements for refugees are “local Nauru and standards" which includes referral to the RoN hospital for specialist care. Unfortunately, we have no contractual or legat basis to provide other specialist services. The exceptions to this are in relation to mental health support and in relation. to the RPC visiting specialists or Tele-health for refugees residing within the RPC. {tis clear that refugees connot access the same levels of care that are available to transferees residing at the RPC and they cannot access an “Australian” standard of care - certainly in relation to access to specialist care anyway. However, legally, they are members of the Nauruan community and the Government of Nauru is responsible just as they are for native Nauruans. All we can do is highlight the areas of inadequacy as regards medical resources and capability - whichwe have done on numerous occasions - but Itis timely that we do it once again, So | shall again write to Dr Brayley highlighting all the matters outlined in your email Regards = —_— Area Medical Director International Health and Medical Services IMS Health Advice Service: 1800 179 659 International SOS Assistance Centre: 02 9372 2468 E-mail: From: Nicholas MARTIN ‘Sent: Wednesday, 22 February 2017 7:48 AM To: ce: ‘Subject: From the SMO Nauru. a '1am writing to express my clinical concerns about how IHMS are Involved with refugees, and to suggest some possible Solutions, | have mentioned these concerns to various people here in Nauru but felt I need to formalise it. In particular, end EI ave discussed this with me; they are in agreement and all share my concerns, and are happy for this email to be sent on their behalf. |'am constantly being told that contractually refugees are not my responsibilty, and that they fall firmly under the care of the Republic of Nauru and the RotNH. | am told that apart from a referral to the RoNH | should not get involved, Indeed, the Overseas Medical Referral System is seen as predominantly a Nauruan system, and the initial input from IMS should be the referral and request, until the final ABF/IHMS interface before emplaning the refugee, | am also aware that their role as Health Service Manager are in constant contact with the clinical director and senior staff at the RONH and are actively involved with them to try and ensure that the RoNH clinicians deliver the service that we need whilst maintaining discretion to keep a healthy working relationship with them. With allthis in mind, there remain significant areas of clinical concern that cannot go left unsaid. If lreferred a patient in Australia to a hospital where | knew that no form of clinical notes would be kept, no feedback Would be given and often the referral would be lost or ignored even after repeated attempts to get the patient seen, | would expect to be up before the courts on a culpable negligence charge, along with the hospital. Ata recent grand rounds meeting at the hospital, listened to the clinical director ask the assembled clinicians to “please write in the notes.” He said too that no notes were being kept and could they start writing things down, This to ‘me is incredible; these things are expected of every doctor or medical student, no matter how junior. | have this morning referred a refugee back again to the RoNH. They have been waiting to be transferred for an MRI scan and specialist review for eighteen months now. | reviewed their paper files. Si separate referrals have been made to the RoNH by IHMS doctors. The patient has been seen once. On the other occasions the referral was ignored. The 2Patient was seen once and no notes of the consultation were kept. A further referral was made and this time a two lined comment of” needs overseas review” was made. Nothing happened after that. Two requests by me to get the patient discussed at the OMR committee have come to nothing, The patient keeps coming back and seeing me, asking what's going on, |/am aware of over thirty requests for overseas review that have been made by IHMS staff to the RoNH, These referrals hhave been ignored, lost or may have been seen but no information about any decision has come to IMS, lam sure there are more. To tell the patients that “ You are the responsibility of the Government of Nauru," seems to be a specious argument to make. These patients are stil presenting to us and demanding answers that we are unable to give. We are willingly referring patients to a broken system that i clinically not fit for purpose. | could go on about the standard of care, hygiene and equipment at the RoNH but | am sure you are aware of the significant shortcomings there. Refugees currently make up about 85% of my workload. | have some ideas as to how this situation could be rectified or at least mitigated. | know that these have been proposed before. Increased visiting specialist teams working at the request of the Government of Nauru. This was atleast some IHMS oversight would be possible, as we would be referring patients knowing that some accountability would exist, and ‘would get replies about our patients. Embedding an administrative assistant in the RONH to track referral, chase clinicians and ensure that patients do actually get considered appropriately. The current situation does not allow our settlement administration staff to do this, The practice of sending electronic copies of referrals as well as hard copies to the Director has not made any difference to patients being seen considered or decisions relayed back to us. This isin spite of good communication with IHMS Staff and the clinical director and director of medical services, Australian Border force have a significant role to play here too as they are key players in requests to move patients overseas. At present, there is an absolute lack of communication from them, for refugees and asylum seekers ale. 1 have asylum seeker patients who have intially been approved for movement to PNG, who, as they could not go to PNG because of visa issues have languished in pain in Nauru. No decision has been made about sending them to Australia or a third country. They have been waiting for many months now. This is despite repeated requests from me about them. How many more times am | expected to raise these concerns? The patients | see return again and again and | am unable to give them any updates asi is in the hands of AF. | need to ensure that these clinical concerns are raised with ABF/DIBP. | would appreciate a reply to acknowledge them and information about what ABF/DIBP/IHMS are doing to address this situation. Clinically this is an unacceptable situation. From a clinical perspective of duty of care we are failing our patients, by knowingly referring them to a system that does them a clinical injustice, ook forward to hearing from you. Yours Nick Dr Nick Martin ‘Senior Medical Officer International Health and Medical Services Pty LtdMonday, 8 May 2017 12:24 PM ‘Nauru HSM ce: Nau s Subject: Re: MM patents | Inctudinglfbn the trail MiB o1cnse ac these tothe ts of RMS for urgent update if we have not, HEI your information we have seen a renewed interest from the Department over the last 3 weeks, Two ofthe cases we have discussed at length and are waiting for a decision from the TPC, ‘We have also struggling with communication back from the Department and we have raised this with them over the last two weeks. HII inking about writing the department a contrac letter but let's see how this week oes, Sent from my iPhone (On 8 May 2017, at 8:49 am, Nauru HSM wrote: | ‘These are all Asylum Seekers who all reside with the RPCs. None are refugees. Kind regards Health Services Manager International Health & Medical Services Pty Lid Nauru Regional Processing Centre PO Box 9 Republic of Nauru Mob: Email naur nsmgaiis.com.au Sydney assistance centre: +61 2 9372 2468 Web: www. internationalsos.com From: Monday, 6 May 2017 10:39 AM 1= Just to be sure, these are all for people within the RPC and not covered by the OMA process? Sent from my iPhone ‘On 8 May 2017, at 8:35 am, Nauru HSM wrote: 600d ming | am writing to ask for some guidance around wording to be used when speaking with Asylum Seekers when there are delays in them being transferred for spetialis treatment ‘due to ABF not approving and not making @ decision? The current lack of information is. {frustrating for clinicians and is leading to the breakdown in trust between Asylum Seckers and IHMS treating clinicians, We have a number of Asylum Seekers sted below, who have been waiting for an ‘extended time well beyond the recommenced timefame for them to have a specialist ‘appointment, including at least one patient who has waited 12 months when the ‘ecornmendation was for them to be seen within a month. All remain symptomatic and some with symptoms worsening. | understand that these cases have been raised with ABF regularly but some advice about what to tell these individuals woule be appreciated |'am aware that there are visa issues with PNG but teling the Asylum Seekers ‘hiss of 10 comfort to thar, Kind regards ean ger International Health & Medical Services Pty Lid Nauru Regional Processing Centre PO Box 9 Republic of Nauru Mob: Email naurunsm@nms,com.eu, Sydney assistance centre: +61 2 9372 2468 Web: wwew.internationalsos.com From: Nauru Senior Medical Officer ‘Sent: Monday, 8 May 2017 10:10 AM To: Nauru HSM Subject: RMM patients co Below are the five patients lam aware of who are asylum seekers and have been Waiting for transfer to a third country for treatment for some time now. | have 2Previously raised them with Heather and Peter. I have been told that they are being raised with ABF weekly. All ofthese patients have breached the deadlines recommended on the RMIM. They are all still symptomatic. Yours Nick Dr Nick Martin Senior Medical Officer International Health and Medical Services Pty Ltd ‘Nauru Regional Processing Centre PO Box9 Republic of Nauru