From: Sent: To: ce: Subject: z cinical concerns. Dear Nick ‘Thanks for your letter regarding your concerns relating to lincal care of refugees on Nauru Fst, You are certainly fot alone n your concems and | have raised these issues with ABF {including John Brayley) on a number of occasions - Without a satisfactory response, | might ad, 'tis most unfortunate that MS and ts clinical staff have been caught inthe middle of aloft. der to understand how this has come sbout, one needs an explanation ofthe background, of which you may already be aware 'HMS were contracted to provide primary care services, mental health support and emergency sesponse services to ‘tonsferees at the Nauru RPC. In order to facitate specialist consultations and management when required, there were {arrangements to have visitng specail, teleheeth consultations and referrals offshore, i quired (and this certainly did happen previously). Originally, with regards to pregnant women, we provided antenatal care on Nauru up to 28 ‘weeks witen pregnant women were referred to Australia forthe final antenatal care and birthing. | think we know the limitations ofthe RoN hospital and so, if we were to provide “Australian” standard of care, we could nat refer patients ‘othe RON hospital, As you know, over the past two years, ABF has put extreme limitations onthe types of patient that ‘we can referral offshore - it does not stop us requesting these transfers but, as we are notin control of that aspect of ‘things, the patients are entirely atthe mercy ofthe decisions made by ABF as regards transfers. You have mentioned the Issue of asylum seekers not being able to goto Port Moresby because of these issues and, recently, we have Fequested thatthe ASF transfer these patients to Australia for medical care - we are awaiting approval The refugee situation is somewhat diferent. The criginal concept from the Australian and Nauru governments was that, ‘when transferees were given refugee status, they would be incorporated into the general Nauru community jest as ‘somebody who Is glen refugee status in Australia would be incorporated into the Australian community As part ofthat incorporation into the Nauruan community, they would acess health services In the seme way native Nauruans Would ‘access these services. The settlement clinic was set up to provide abridge 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 contrectual arrangements that IHMS has in relation tothe settlement cnc refers to. “local Nauruan standards”. The reason for paper records was that this was local Naurvan standards and after the refugees had gone past their initial phase of attending the settlement clinic, these records would be incorporated into ‘the Ron hospital record. However, tis transition of refugees into the local community has, on the whole, not occurred {ot reasons which were easly predictable (but ignored in intial planning by Nauruan and Austrlian governments} and Certainly outside the control of IMS. So, as a result, the contractual arrangements for refugees are “local Nauru and Standards” which includes referral tothe ReN hospital for specialist care. Unfortunately, we have no contractual or legal basis to provide other specialist services. The exceptions to this are In relation to mental heath support nd in relation {to the RPC visting specialists or Telehealth for refugees residing within the RPC. ‘tis lear that refugees cannot access the sarne levels of care that are available to transferees residing atthe RPC and they cannot access an “Australian” standard of care certainly n relation to access to specialist cae anyway. However, legally, they are members ofthe Nauruan community and the Government of Nauru is responsible jst ss they are for ‘native Nauruans All we can do is highlight the areas of inadequacy as regards medical resources ad capabllty- whichWwe have done on numerous occasions - but Its timely that we do Itence again. So! shal again write to Dr Brayley ‘highlighting all the matters cutlined in your email Regards or ‘Area Medical Director International Health and Medical Services TT IMS Health advice Service: 1800 179 659 International SOS Assistance Centre: 02 9372 2468 Lam wrting to express my cla concn about how IHMS are involved with refugees an to sugges some poste salons have mestiones these concerns to varios people her in Nauru but fl need to formalise In partes, ord MMM reve cose this wih me; they are in agreement and allsare ‘iyconcerns andre hapey fortis emal to Be sent on thelr beat ''am constantly being told that contractually refugees are not my responsibilty, and that they fll firmly under the care ‘of the Republic of Nauru and the RoNH, | arm told that apart from a referral to the ReNH | should not get involved Indeed, the Overseas Medica! Referral System is seen as predominantly a Reuruan system and the inal input from |HHMS should be the referraland request, until the final ABF/IHDMS interface before emplaning the refugee. ‘2m ao aware thet In theicrote as esth Service Manager arin constant contac with he cal sirector and senor stat at te HONK and ae actively involved with hem tor and ensure hate RaNt cna dellver the service that we need whist maintaining dsretion to kep a healthy werkng relationship wth ther, (With allthis in mind, there remain significant areas of clinical concern that cannot go left unsaid, If 1 referred a patient in Australia toa hospital where | knew that no form of clinical notes would be kept, no feedback {Would be glven and often the referral would be lost or ignored even after repeated attempts to get te patient seen, | ‘Would expect to be up before the courts on a culpable negligence charge, along with the hospital [Ata recent grand rounds meeting atthe hospital, listened to the nical director ask the assembled dinkians to “please wtte inthe notes.” He sald 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 junler. ‘have this morning referred a refugee back again to the RONH. Thay have been walting tobe transferred for an MR? scan and specialist review for eighteen months now. | reviewed thelr paper fils. Six separate referrals have been made tothe RoWH by IHMS doctors. The patient has been seen once. On the ether occasions the referral wes ignored. The 2patient wes sen once and no notes ofthe consultation were kept. A further raferal was made and this ime a two ined ‘comment of * needs overseas review” was made. Nothing happened after that, Two requests by me to get the patient, alscussad at the OMR committee have come to nothing, The patient keeps coming back and seeing me, asking what's toing on, ''am aware of over thirty requests for overseas review that have been made by IHMS staff tothe RONM. These referals have been ignored, lost or may have been seen but no Information about any decision has come to MS. am sure there are more, ‘To tellthe patlonts that * You are the responsibilty ofthe Government of Nauru,” seems to be a spectous argument to ‘make. These patients ae stil presenting to us and demanding answers that we are unable to give. We are willy referring patients to a broken system that is clinically not ft for purpose. | could go on about the standard of care, fhygiene and equipment atthe RoNH but | am sure you are aware ofthe significant shortcomings there. Refugees ‘currently maka up about 85% of my work "have some ideas as to how this situation could be rectified or atleast mitigated. know that these have been proposed before. Increased visiting specialist teams working at the request ofthe Government of Nauru. This was a least some IHMS ‘oversight would be possible, as we would be referring patients knowing that some accountabllty would exist, and would gt replies about our patients. Embedding an administrative assistant in the RoNH to track referal, chase clniciens and ensure that patients do ‘actualty get considered appropriately. The current situation does not allow our settlement administration staf to do this. ‘The practice of sending electronic coples of referrals as well s hard coples to the Director has not made any difference ‘0 patients being seen considered or decisions relayed back tous. This isin spite of good communication with IHMS ‘staff and the clinical director and director of melical services. Australian Border force have a significant role to play here too as they are key playes in request to move patients ‘overseas. At present, there ls an absolute lack of communication from them, for refugees and asylum seekers alike. | hhave asylum seeker patients who have intially been approved for movement ro PNG, who, as they could not goto PNG ‘because of visa issues have languished in ain in Nauru. No decision has been made about sending them to Australia or third country. They have been waiting for many months now. Ths ls despite repeated requests from me about them, How many more times am | expected to raise these concerns? The patients ee retum again and again and} am uneble ‘to elve them any updates as Its inthe hands of ABP. | need to ensure that these clinical concems are ralsed with ABF/DIBP. | would appreciate a reply to acknowledge them and information about what ABF/DIBP/IHMS are doing to address this situation, Cinally this lan unacceptable situation, From a clinical perspective of duty of care we are falling our patients, by knowingly referring them to a system that does them clinical injustice, ‘ook forward to hearing from you. Yours Nick Dr‘Nick Martin Senlor Medical Officer International Health and Medical Services Ply Lid‘Monday, 8 May 2017 12:24 PM Nauru HSM Naw se Re: RM patents Incl te a, MII ese 2 nese tothe et of RMS for urgent update we have no MII your nformason we hove seen renewed interest fom the Deparment over the lst3 weeks, Two ofthe cases we have discussed at length and are wating fore detson trom the Toe \We have also struggling with communication back from the Department and we have two weeks. ised this with them over the last HI stinking abour writing tne department a contract eter but lets se how ths week goes Sent from my iPhone — ‘Tse rl yam Seles who al side whe RPC. Noe ae rege Kd ogcds ean Services Manager International Health & Medical Services Pty Lid Nauru Regional Processing Centre FO Box 8 Republic of Nauru Mob: Email-naun Tns.com a Sydney assistance centre: +81 2 9372 2468 Webs 1wirw intemationalsos.com From: ‘Sent: Moncey, 8 May 2037 10:39 AM Tor Naurs HSM ce Nauru Senior Medical Ofcer ‘Sunects Ree RP 1—_ ‘st tobe sure, these are all for people within the RPC and nt covered by the OMIA process? Sent from my Phone (On B May 2017, 8:35 am, Nauru HSM wrote: Good morring {gm wating to ask for some guidance around wording to be used when speaking with ‘Asylum Seekers when there are celays in them being transferred for specialist Seatment {due to ABF not approving and not making @ decision? The current lack of ifermsterie {usrting for clnicians snd is loading othe breakdown In trust between Acjurn Seekers and HIS treating clinicians. We have 2 numberof Asylum Seekers, ted below, who have been waling fr an ‘extended time well beyond the recomended timeframe for them fo Have tapectlet ‘appointment, including atleast one patient who has waited 12 monte wren he ‘Recommendation was for them te be seen within a month. All remain eymstemate and Some wit symptoms worsening. | understand that these cases have been lced ‘ABE regularly but come advice about wha fo tell hese individuals woud bo approcited |'am awore tht there are visa issues with PNG but teling the Asylum Seekers fie ar 1 comfort to them, Kind regards Feealth Sermces Manager International Health & Medical Services Pty Lio Nauru Regional Processing Centre PO Box 9 Republic of Nauru Moa Emait naulu scans, Colle Sycney assistance centre: +61 2 9372 2468 ‘Web: yaww.internationalsos. com Fromm: Nauru Senior Medical Omer Sent: Monday, 8 May 2037 10:10 AM To: Neuru HS Subject: RHM patients oo Betow are the five patients 1am aware of who are asyium seekers and have been waiting for transfer to a third country for treatment for some time now. I have 2previous sed hem vith Inve been tos hat they te beg ‘alsed with ABF weekly ll ofthese patients have breached the deadlines recommended on the ANIM. They are all stil symptomatic. Yours Nick Dr Nick Martin Senlor Medical Officer Intemational Health and Medical Services Pty Ltd ‘aunt Regional Processing Centre, PO Box Republic of Nauru Webs aot on ° Retusmneniitrisena