Allegations of abuse, neglect and self-harm

2.1        This chapter examines the abuse, neglect and self-harm alleged to have occurred at the Regional Processing Centres (RPCs) in the Republic of Nauru (Nauru) and Papua New Guinea (PNG).

2.2        These allegations are not new. Numerous allegations of misconduct and neglect, both minor and major, have been made since the establishment of the RPCs. Many of these allegations have been outlined, in detail, in previous inquiries into these and related matters.

2.3        This report is not intended to duplicate the evidence presented to previous inquiries, and should be read in conjunction with those previous reports. However, this chapter will set out the range of allegations of abuse, self-harm and neglect, and discuss the new corroborative evidence from both primary and secondary sources in regards to historical claims of abuse, as well as claims of ongoing abuse and neglect.

The Nauru files

2.4        On 10 August 2016, The Guardian Australia published over 2,000 incident reports from the Nauru RPC.[1] These de-identified reports, referred to by the Guardian Australia as 'the Nauru files', detail incidents which were recorded between 2013 and 2015. At the time of their release, the Department of Immigration and Border Protection (the department) stated that the reports detailed 'unconfirmed allegations or uncorroborated statements and claims' and not proven facts.[2] Some of the reports contain allegations made by asylum seekers and refugees, as reported to RPC staff. Many contain accounts of incidents which staff members witnessed first-hand, or in which they were personally involved.

2.5        Many of these incident reports, both individually and collectively, corroborate much of the evidence presented to the committee from secondary sources. This report will refer to the incident reports and, where appropriate, will quote the words of asylum seekers and refugees (as recorded by the reporting staff member) directly.

Allegations of abuse and self-harm among refugees and asylum seekers

2.6        The committee heard evidence about widespread allegations of abuse and neglect both within RPCs, and in the Nauruan and Papua New Guinean communities. The committee also heard that self-harm and suicidal ideation among refugees and asylum seekers of all ages is extremely common.

2.7        This evidence presented to the committee was largely from secondary sources. However, the committee has noted particular incident reports contained in the Nauru files, where those reports further illustrate an allegation made by a secondary source. The committee has also noted that other organisations, including Amnesty International, have conducted their own first-hand confidential interviews with refugees and asylum seekers, and has made reference to those interviews where the subject matter further illustrates allegations made by a submitter.[3]

Nauru

2.8        The allegations of abuse, self-harm and neglect among refugees and asylum seekers on Nauru relate to the facilities provided to refugees and asylum seekers, staff conduct, harassment and attacks in the Nauruan community, widespread poor mental health, the provision of healthcare services, and the protection of children.

RPC living and recreational facilities

2.9        Many submitters raised serious concerns about the living and recreational facilities at the Nauru RPC. Some of these submitters discussed first-hand experiences of difficult living conditions, while others recounted evidence provided to them by refugees and asylum seekers detained within the RPC.

2.10      As outlined in previous inquiries, the natural environment on Nauru presents challenges. The RPC is located at the centre of a phosphate plateau, with little natural shelter from the heat.[4] Temperatures regularly exceed 30 degrees Celsius,[5] and humidity levels can reach between 70 and 90 per cent.[6]

2.11      The Human Rights Law Centre (HRLC) submitted that the RPC facilities do not provide relief from the weather conditions.[7] Human Rights Watch (HRW) stated that heat levels in the crowded tent accommodation can reach 45–50 degrees Celsius, and explained that in the high humidity environment, mould grows quickly on tent walls and ceilings, and torrential rain fall pools water on the floor.[8] It noted that approximately one third of the total number of refugees and asylum seekers currently on Nauru remain in RPC tent accommodation.[9]

2.12      In February 2015, the then-service provider Transfield Pty Ltd advised the department that tented accommodation in the Nauru RPC failed to meet Australian Mould Guidelines, with more than 10 metres square of visible mould growth in all tents.[10] The department agreed that mould is a persistent problem in tented accommodation.[11]

2.13      In May 2016, the International Human Rights and Conflict Resolution Clinic of Stanford Law School (Stanford Law Clinic) interviewed a number of individuals who had formerly been detained at the Nauru RPC.[12] These interviews were conducted for the purpose of gathering evidence to provide to the Prosecutor of the International Criminal Court (ICC) in support of a request that the Prosecutor prosecute Australia for crimes against humanity.[13] Interviewees described a lack of air conditioning or fans for many months, and the subsequent installation of just one fan per tent, as well as personal belongings being repeatedly damaged by flooding.[14] An incident report contained within the Nauru files similarly notes concerns from a Save the Children Australia worker about children with rashes on their necks, chests and arms consistent with heat rash.[15]

2.14      The committee heard evidence of both historical and ongoing overcrowding within the RPC. The United Nations High Commissioner for Refugees (UNHCR) advised the committee that accommodation facilities remain overcrowded.[16] Stanford Law Clinic interviewees described that they had at times been required to sleep on a blanket on the ground, or a military style cot.[17] Several others described being held in overcrowded tents with multiple families, with up to 50 people in one tent.[18] They also alleged that bathroom facilities were inadequate, with less than 10 toilets and showers available for approximately 100 people.[19]

2.15      There were also allegations that food and water supplies on Nauru are restricted, and not in adequate supply. In October 2016, the UN Committee on the Rights of the Child (CRC) commented on the limited access to basic services in Nauru, including a lack of safe and clean drinking water in a high humidity environment, leaving children and families 'vulnerable to dehydration and other serious health problems'.[20] Former detainees have also reported these concerns, alleging that water shortages could last up to one week during their detention, and that this would prevent showering and lead to water rationing.[21] One detainee also alleged that at times, contractors would replace the fresh water in the showers with salt water.[22] In March 2017, the department advised that domestic water on Nauru is provided through 'reverse osmosis of sea water' and 'imported bottled water', both of which are 'freely available to all staff and all [refugees and asylum seekers]'.[23] Discrepancies remain between evidence by the department and witnesses about how much clean drinking water was available to refugees and asylum seekers.

2.16      The Australia Director of HRW, Ms Elaine Pearson, argued that RPC facilities are not sufficient to provide either privacy or security (particularly at night).[24] Several leaked incident reports reflect this argument, and indicate that a lack of personal space contributes to a feeling of being unsafe. These include families accused of bullying one another,[25] individuals accused of threatening other detainees,[26] a single mother who advised that a man kept entering her tent,[27] and women who stated that they had been the victims of harassment,[28] and sexual harassment.[29]

RPC staff

2.17      Allegations of poor staff conduct have also been addressed in previous inquiries into these matters. In 2015, Mr Phillip Moss AM concluded that it was likely that guards had exploited adults and children in exchange for access to shower facilities, that women had been raped, and that adults and children had been physically and sexually assaulted.[30]

2.18      The committee heard allegations of unprofessional conduct by some members of RPC staff, including conduct designed to deliberately antagonise and taunt asylum seekers and refugees. The allegations from secondary sources and confidential interviews are reflected in many of the incident reports contained in the Nauru files.

2.19      Amnesty International reported that some RPC service providers would call asylum seekers by their boat or refugee identification numbers, and alleged that some Wilson Security guards called asylum seekers 'rubbish'.[31] In its response to this submission, the department noted that this issue had been dealt with by the select committee in August 2015, and that the service provider in question had apologised.[32] The department stated that there is no evidence that this practice currently exists.

2.20      Stanford Law Clinic interviewees likewise described physical altercations with security staff (as well as locals and fellow detainees), an environment that permitted rape, and sexual blackmail perpetrated by guards (as well as locals and fellow detainees).[33] Others described exchanging sexual favours for longer shower times or goods like cigarettes, and one man alleged that he had been gang raped by men wearing Wilson Security uniforms.[34]

2.21      RPC staff members have reported hearing other staff members making disparaging comments about asylum seekers, including saying that they should 'go back to their country and get out of Nauru'.[35] The Nauru files also contain allegations of Wilson Security staff swearing at asylum seekers,[36]  grabbing and pushing them,[37] and subjecting them to invasive security measures.[38]

2.22      In November 2014 a Save the Children worker recorded that a female detainee alleged that a Wilson Security cultural advisor had spoken improperly to her about her recent rape, causing her to feel sick and want to hit her head. The worker recorded that the woman had described the cultural advisor stating the following:

• 'Why? Things that happen to you are as common as going to the bathroom or eating food'
• 'Rape in Australia is very common and people don't get punished'
• 'If that happened to you why didn't you scream at the time? '
• 'You have to take it out of you head if you go to Nauru then he [the perpetrator] could be your neighbour or if you go to [redacted] then he could be on the plane next to you. You also have to teach your son to treat this man nicely'
• 'There are no charges being brought against this man, this was something very normal and very common'.[39]

2.23      Extremely serious allegations of serious criminal conduct by staff members, including against children have also been made. These allegations spread across the available incident reports, from 2013 through to 2015. The reports detail troubling allegations, including staff members allegedly sexually assaulting a child,[40] choking a child,[41] hitting a child across the face,[42] spitting at a child,[43] asking a child to lift their shirt and display her stomach,[44] pulling a child's hair,[45] otherwise physically assaulting children,[46] and physically removing a child from a tent and then later threatening to assault the child.[47] One incident report details a staff member having to be physically restrained by other staff members as they tried to hit a child in the RPC canteen.[48]

2.24      In September 2015, a Save the Children Australia staff member reported that they had found a child who was crying and shaken, and who alleged that a Wilson Security guard had become angry at him, grabbed him around the throat, and hit his head against the ground twice. [49] The worker recorded observing the child then asking the guard repeatedly 'why did you hit me?' Further incident reports alleged that a security guard had deliberately cut down a shade cloth upon which children were sitting, causing them to fall to the rocky ground.[50] In another incident, a Save the Children Australia teacher recorded that her assistant had asked a guard for a four minute shower, to which the guard replied that he would do so in return for sexual favours, and also expressed a desire to watch a boy or girl showering.[51] In another, a child alleged that a security guard had threatened to call the Nauruan Police about him, and have him locked in a cell forever, and then pretended to call the police.[52]

2.25      Doctors for Refugees (DFR) raised concerns about the conduct of staff members in Australia. They submitted that an adult woman who had been hospitalised in Australia for depression and suicide attempts during her pregnancy told the organisation that she was forcibly returned to Nauru five months after giving birth.[53] DFR stated that the patient provided the following account of her transfer:

Woke at 6am in bed and officers in the room. She was wearing undergarments and officers would not allow her to put on her clothes prior to driving to the airport. Officers took video footage of her during the drive. Dragged onto the plane sustaining scratches on elbows, knees and back of neck. Photographs demonstrate an abrasion to one knee, bruising above the right elbow and three large bruises on the upper back. She was not permitted to breastfeed her son between 6am to 5pm. Her husband was transferred in a different vehicle.[54]

2.26      DFR also submitted that an unaccompanied minor who had been detained in the Brisbane transit centre and placed on 'high security check' was forcibly transferred to Nauru against her will.[55] DFR stated that 'witnesses have reported to DFR that she was dragged across the courtyard of the detention facility screaming in protest'. DFR noted that soon after the woman returned to Nauru she set herself on fire.

2.27      The committee also heard allegations of unprofessional conduct at senior management levels. Amnesty International stated that it had conducted a confidential interview in September 2016 with a managerial-level service provider who stated that being privy to conduct at the higher levels of office 'really ate at my soul'.[56] The staff member described the 'gut-wrenching' feeling of hearing Australian Border Force personnel speaking about asylum seekers and refugees as 'pieces of meat—like cattle', and laughing at suicide attempts.[57]

2.28      The department provided a response to Amnesty International's October 2016 report, Island of Despair–Australia's 'Processing' of Refugees on Nauru'.[58] The department stated that it had reviewed the circumstances of the individual cases described in the report. It asserted that a wide range of the claims were false, and that some had been aired previously and had either been refuted or addressed.[59]

Harassment and attacks

2.29      The committee heard evidence of refugees and asylum seekers being afraid of venturing from the camp into the local Nauruan community because of alleged assaults and harassment. From February to October 2015, asylum seekers and refugees at the Nauru RPC could leave at a designated exit point during agreed hours.[60] Since October 2015, the centre has been designated as being open 'all the time'.[61] The department described the arrangement in its submission to this inquiry, as one which enables refugees and asylum seekers to 'venture beyond the RPC without restriction'.[62]

2.30      A number of submitters outlined concerns about physical attacks towards asylum seekers and refugees by local residents, as well as antisocial and aggressive behaviour including throwing bottles, spitting, swerving vehicles towards refugees and asylum seekers, and causing property damage.[63] Amnesty International submitted that refugees had been viciously attacked in the Nauruan community, including one man who reported being attacked by a group of local men in mid-2016, kicked from his motorbike and beaten, suffering serious head trauma.[64]

2.31      Both HRW and Australian Women in Support of Women on Nauru (AWSWN) submitted that female refugees and asylum seekers have reported widespread sexual assault and harassment, including groping, touching, explicit threats, and attempted rape.[65] Several incident reports in the Nauru files reflect these allegations, including reports of sexual harassment at the hands of fellow refugees and asylum seekers,[66] rape,[67] and sexual propositions and harassment from local Nauruan men in public places.[68]  Ms Pamela Curr of AWSWN stated that in May 2015 a woman in Nauru had been gang raped by a group of local men who had attacked her, doused her with petrol and burned her. Ms Curr stated that the woman in question fell pregnant as a result of this rape, and had to be transferred to Australia for an abortion.[69]

2.32      In April 2016 it was reported that a refugee who had been settled on Nauru was raped while suffering an epileptic seizure, and had since attempted suicide.[70] The report, which noted that abortion is illegal in Nauru and only sometimes legal in PNG, stated that the woman had been transferred to PNG. On 7 May 2016 it was reported that the Federal Court of Australia (FCA) had ordered that the Minister for Immigration and Border Protection not to organise an abortion procedure in PNG.[71]

2.33      HRW explained that in response to this harassment and violence, refugees and asylum seekers on Nauru have tried to alter their behaviour in order to alleviate the risk of attacks. Ms Pearson advised that women and young girls reportedly rarely leave the RPC alone.[72]

2.34      There are allegations of misconduct by Nauruan police. Amnesty International advised that service providers and refugees had both confidentially disclosed instances where police had torn up a refugee's written statement, forcing them to sign a statement the police had pre-written, robbed asylum seekers, and assaulted them.[73] Amnesty International also outlined the case of a man who had allegedly been arbitrarily arrested and incarcerated for over three months, after which time he was harassed and bullied by local police who placed him in a dark room for over four hours and eventually placed him in solitary confinement on the charge of 'threatening a Nauruan citizen'.[74] It also stated that a service provider had confidentially disclosed an instance in 2016 where local police were called and entered the RPC after a woman had taken her dessert away from the designated eating area. The police allegedly dragged the woman out of the RPC and to the police station.[75] In an incident report recorded in May 2015, a man alleged that he had been assaulted by local police for refusing to submit to an alcohol breath test. He reported that he was beaten, his clothes were torn off, and he was placed in a cell in only his underwear.[76]

2.35      Amnesty International also submitted that an Australian Federal Police (AFP) Officer had dealt improperly with a minor.[77] It submitted that an asylum seeker was jailed in June 2016 for allegedly 'threatening a Nauruan citizen', and had been taken to the local police station together with his eight year old son. The father alleged that the an AFP officer at the station questioned his son alone for 20 minutes, and then declined to provide him with a copy of his son's statement, stating that he would be contacted about it later. The father alleged that when he was contacted one week later and advised to leave the RPC and collect the statement, he was subsequently arrested outside the RPC by a group of fifteen Nauruan police officers and approximately five AFP officers.[78] Amnesty International stated that the man was held in prison for 96 days, including a period in solitary confinement. The man alleged that during his imprisonment he attended court several times, but was never permitted to speak. Amnesty International stated that the man was eventually found not guilty, and released on 7 September 2016.

Widespread poor mental health and persistent high levels of self-harm

2.36      The committee heard evidence that refugees and asylum seekers on Nauru express serious and persistent mental health concerns.

2.37      After visiting Nauru in July 2016, Amnesty International reported that almost every person with whom its researchers spoke reported a mental health issue of some kind, and that almost every person said those problems began once they were transferred to Nauru.[79] High levels of anxiety, mood swings and trouble sleeping have been widely reported.[80] Amnesty International reported that a woman had watched a man set himself on fire one week after giving birth to her child. After this, she lost her breastmilk, barely spoke, and stopped leaving the family home.[81] HRW, which also visited the RPCs, echoed this, noting that nearly all asylum seekers and refugees interviewed by HRW expressed concern about their mental wellbeing.[82]

2.38      Media reports note that two detainees have self-immolated while in the Nauru RPC. Mr Omid Masoumali, 23 years old, was filmed pouring petrol on himself and setting himself alight. He was transferred to Australia for medical treatment but died of his injuries. His wife alleged that prior to being airlifted, he went without medical care for two hours, and it was a further eight hours before pain relief was administered to him.[83] Ms Hodan Yashin, a 21 year old Somali woman, also set herself alight and was airlifted to Australia for treatment. She was reported to have suffered severe burns to her upper body and face.[84]

2.39      Several individuals interviewed by the Stanford Law Clinic also described widespread self-harm, alleging that self-harm was 'everyday business' in the RPC, and depression was a constant battle.[85] One interviewee described to the Clinic how he attempted to kill himself on seven different occasions, revealing the large scars on his stomach where he had slit himself open.[86]

2.40      Numerous incident reports contained in the Nauru files reflect these allegations of widespread poor mental health and self-harm. Although it is unclear whether the database of leaked reports represents all incident reports during the relevant periods of time, the reports which have been included indicate that:

• from January to October 2015 there were 25 recorded incidents of actual self‑harm (six of which were categories as 'critical' incidents, and 19 'major' incidents);
• from February to December 2014 there were 37 recorded incidents of actual self-harm (3 'critical', 10 'major', 14 'minor', and 10 'information'); and
• between 2014 and 2015 there were 62 recorded instances of actual self-harm (ranging in classification).

2.41      The reports of self-harm included in this database, and as referenced by secondary sources, include instances of people self-harming by pouring petrol over themselves,[87] drinking insect repellent,[88] swallowing screws,[89] drinking cleaning fluids,[90] swallowing stones,[91] ingesting baby bottle sterilising tablets,[92] hanging,[93] and cutting themselves.[94]

2.42      Incident reports outline numerous instances of people refusing food and water.  The classifications associated with these recorded incidents varied from mere 'information', through to a 'critical' incident of a pregnant woman starving herself in September 2015.[95] In some of these recorded incidents it was alleged that individuals were deliberately doing this to try and force officials to bring them to Australia,[96] while others stated that individuals told staff members that they had no choice but to stop eating.[97]

2.43      HRW explained that children and young people exhibit higher-than-normal levels of bedwetting, nightmares, and poor behaviour.[98] Mr Daniel Webb of the HRLC submitted that some children have been so traumatised that they have received inpatient psychiatric treatment.[99] One former teacher at the Nauru RPC stated that within 15 months, one of her former students who had been 'one of the brightest, bubbliest students' was taking psychotropic medication and would 'cry silently'.[100] Amnesty International submitted that one young girl, who had spent 18 months living in a tent, would vomit, wet her bed nightly, and wake up screaming.[101]

2.44       There are also numerous incident reports alleging self-harm on the part of children,[102] and threats to harm themselves.[103] Save the Children teachers recorded a number of instances during which their students disclosed thoughts of self-harm and suicide.[104] The incident reports also indicate a concentration of threats to self-harm among students who were attempting to prevent the closure of their RPC school.[105]

2.45      In one particularly concerning incident, a Save the Children Australia staff member recorded observing a child 'in a fit of screaming and flailing her arms', who had climbed onto the top of a store room and threatened to jump.[106] The worker recorded that three different staff members tried to calm the child down for fifteen minutes, but she continued scream, scratch her face (causing her head to bleed). The worker stated that the child appeared to be 'in a far off mental space'. Two witnesses were reported to have stated that the child had a meltdown when a security guard tried to pull a chair from her hands and she fell backwards, striking her head. This incident was initially reported by the Save the Children Australia worker as a minor incident of accident/injury and non-compliance. It was subsequently downgraded to 'information'.

Healthcare services

2.46      The committee heard significant concerns about the standard of healthcare provided to refugees and asylum seekers in Nauru, and the manner in which medical transfers to Australia and PNG take place. Incident reports also demonstrate a lack of faith in the provision of adequate medical services on the part of asylum seekers and refugees, especially in the case of pregnant women.

2.47      The Australasian College of Emergency Medicine (ACEM), the peak organisation for emergency medicine in Australasia, explained that asylum seekers and refugees have complex healthcare needs, which can arise due to the means by which they arrived at an RPC, and as a result of the conditions once they are housed in the RPC.[107] They may be vulnerable to infectious diseases, poor nutritional health, and developmental risks associated with poor mental health in the case of children.[108]

2.48      In October 2016, the United Nations Committee on the Rights of the Child (CRC) raised concerns in relation to the care available to mothers and young children on Nauru.[109] It highlighted in particular the lack of health services available for asylum seeking and refugee children, 'many of whom have developed chronic conditions as a result of living in overcrowded and unsanitary conditions, and the fact that the main medical provider in the [RPC] has no paediatrician.[110] Amnesty International submitted that tuberculosis is widespread at the Nauru RPC, and that the dampness in the RPC and the phosphate in the air are particularly damaging for the illness.[111] It reported that an asylum seeker on Nauru stated that approximately 40 children at the Nauru RPC had tuberculosis.

2.49      The committee heard evidence from media reports and medical organisations which submitted to this inquiry of serious concerns about the healthcare services being provided to refugees and asylum seekers in Nauru. In 2017, a young woman and her premature son were medically evacuated to Australia in critical condition, following the performance of a caesarean section in Nauru.[112] In January 2017, DFR reported that it had requested the medical transfer of a pregnant woman from Nauru to Australia.[113] DFR advised that the 37 year old woman was 35 weeks pregnant, and that the baby was in breech. It explained that the woman had previously had a miscarriage on Nauru and that she had a large tumour on the wall of her uterus, meaning that she faced a complex and potentially life threatening delivery. The report also alleged that the woman had been prescribed an antidepressant drug (citalopram) which may cause harmful effects on the human foetus, according to Australian guidelines. Following a period of intensive media scrutiny, on 3 February 2017 it was reported that the woman was going to be flown to Australia to give birth.[114]  

2.50      The Australian Medical Association (AMA) submitted that it did not believe that asylum seekers and refugees in Nauru and Manus can access the same level of healthcare which a person in Australia would receive.[115] It explained that a number of asylum seekers have sought medical intervention from the AMA, and that it has obtained medical records from those patients where the written consent of that patient has been obtained.[116] Acknowledging that the information it provided could not be independently verified,[117] the AMA expressed its concern in relation to the care being provided to certain individuals, citing the following case studies from Nauru:

• a woman who had engaged in self-harm, as well as allegedly having been the victim of verbal, physical and sexual abuse while in Nauru. The AMA stated that the woman had been prescribed Quetiapine, Lorazepam and Mirtazapine 'with severe side effects';[118]
• a woman whose weight had reportedly fallen by more than half, and whose kidneys were failing;[119] and
• a man who was the victim of a physical assault in Nauru, including a strike to the head. The AMA stated that one month after the attack the man had a CT scan and was advised that he had a broken bone in the centre of his skull. The AMA stated that this diagnosis was later reviewed to 'suffering from a mental illness'.  The patient's wife was allegedly told that no more could be done for his mental health and that the mental health doctor would recommend electric shock treatment. The AMA also stated that a doctor in the Nauru RPC placed the patient on 16 medications. [120]

2.51      The AMA explained that it had experienced difficulties keeping in contact with asylum seekers and refugees who had approached them for assistance, and on whose behalf the organisation had made representations.[121] For a third party to access a patient's medical records, a patient is required to provide a 'legally valid' signed consent form to IHMS.[122] The AMA explained that this process posed problems, because some health concerns had been raised with the AMA by a third party, and, while the AMA could raise the matter with the department, it could not contact the patient directly.[123] It also explained that technological barriers could frustrate the process of obtaining records. It explained that it would receive signed consent forms via a mobile phone photograph which had been sent by text message.[124] It also argued that patients themselves would be prevented from viewing their own records where they were provided in a digital format, as access to computers was severely limited.[125]

2.52      The AMA submitted that in each of the cases it cited in their submission, the AMA had no knowledge of the patient's current medical situation because they had not been provided with updated information, or had not been able to obtain the consent of the patient beyond the information originally provided.[126]

2.53      IHMS explained that it has a client confidentiality and privacy policy, and does not comment on individual cases 'without being able to properly identify the patient and receive their consent to discuss their case in an open and transparent way'.[127] IHMS stated that it was concerned that AMA had 'chosen to use a series of emotive quotations to imply unsatisfactory medical treatment rather than providing a systematic, professional discussion of the cases as would normally be undertaken by medical professionals'. IHMS stated that they are willing to discuss cases which the AMA wishes to raise if it can provide a valid consent from the patient authorising IHMS to do so.[128]

2.54      The committee noted that many of the concerns raised by the AMA were also raised by DFR. DFR explained that doctors who are members of the organisation conduct independent medical analysis of refugees and asylum seekers' cases, with their written consent, and make clinical recommendations which are submitted back to IHMS.[129]

2.55      DFR advised that it currently has 188 active cases for individuals in Nauru and Manus who have self-referred to DFR for medical assistance, and 26 cases related to individuals in Australia.[130] DFR explained that in 26 per cent of its cases, 'severe and deteriorating mental health is the primary reason for the referral', and noted that this does not include cases where an individual is experiencing more than one condition, and the primary reason for the referral is not a mental illness.[131] DFR stated that in more than 30 per cent of its cases the primary reason for the referral was a suicide attempt.

2.56      DFR expressed concern about the care being provided to certain individuals, citing the following case studies from Nauru:

• a child whose mother suffered from severe depression and had attempted suicide multiple times, and was so disengaged from her son that she could not tolerate his touch or his presence;[132]
• a Clinical Professor recommended that a child be transferred to Australia for testing as the diagnosis could be tuberculosis, syphilis, or yaws. The child was not transferred.[133]
• a child who had been identified as suffering from a possible developmental delay three years earlier. A child and adolescent psychiatrist recommended that the child be transferred immediately to Australia to access specialist services. The child's medical records indicated that the child had not received specialist paediatric developmental assessment or treatment;[134]
• a child who had been diagnosed with hyperactivity disorder, and was recommended for a formal developmental assessment for Autism Spectrum disorder in October 2015. In February 2016 another psychologist recommended a psychiatry referral. In April 2016 a further psychologist recommended a referral to a child psychologist. DFR stated that 'there is no evidence in his case file of these recommended referrals occurring and no developmental assessment has been done';[135] 
• a child with sinus pain who was placed under full sedation three times by a dentist for investigation, placed on six courses of antibiotics, and was taking daily medication. DFR questioned the testing which had been undertaken in relation to the child's care, and stated that it had corresponded with IHMS in relation to the diagnosis. DFR stated that 'IHMS insists that the diagnosis is dental abscess despite no response to multiple antibiotics', and four diagnoses of 'maxillary sinusitis' on four separate occasions;[136]
• a child had sustained a fracture in the forearm of his dominant hand in
  May 2015.[137] DFR reviewed his X-ray and recommended that the child be referred to an orthopaedic surgeon. DFR stated that IHMS dismissed this recommendation and it was only after the X-rays appeared in the Australian media that the operation DFR had recommended, took place. DFR stated that 'notably this involved flying an Australian orthopaedic team to Nauru, at great expense, to perform surgery in June 2015, a delay of one month following the original injury'. DFR stated that in November 2015, a medical officer at the Republic of Nauru Hospital noted in the child's medical records, 'patient was not seen and evaluated by physiotherapist!! No physiotherapy was done since my referral last August'. DFR stated that one year later the child was experiencing severe arm pain and impaired function of his dominant hand. DFR also stated that the child's mother informed them that an orthopaedic surgeon had been flown from Australia one month ago but the 'surgery room was not ready for operation'.[138] 

2.57      Amnesty International raised similar concerns, stating that asylum seekers and refugees reported that 'the principal response to their mental health issues has been the prescription of strong sedatives and anti-psychotic medication'.[139]

2.58      The committee noted in particular the following compelling case from DFR, which the committee regards as an example of the difficulties associated with accessing adequate services on Nauru.

Case Study:

(Name redacted) was [a child] upon his arrival to Nauru in September 2013 and assessed as having 'mild PTSD symptoms.' His father took him to Torture and Trauma counselling and he initially coped well. In April 2014, IHMS doctor and psychologist noted he was being bullied because of a speech impediment. He was referred to a paediatric psychiatrist. The psychiatrist noted 'speech production disorder' and referred to an Ear Nose and Throat surgeon (ENT) for assessment of reduced tongue movement. In May 2014 the child presented with a dental infection and later that month represented after assault by another child at school. The psychologist noted 'he is teased daily about his speech impediment.' A 'high priority referral' unsigned in his case file is dated June 2014. His father presents to IHMS multiple times over 3 months to check this referral—psychologists and multiple general practitioners confirm an existing referral and note escalating this to the Senior Medical Officer on Nauru several times.

(Name redacted)'s father submitted a complaint through Transfield services regarding the delayed specialist review and received written reply from the Health Services Manager on the 13^th of May: 'I do not have a date for specialist to visit Nauru at this time. (Name redacted) is on the waiting list and we will notify you when we have a date for this service. ' On the 22^nd of May 2014 the Senior Medical Officer for IHMS on Nauru submitted a Recommendation for Medical Movement from Nauru to Australia for oral surgery and speech therapy to the Area Medical Director. [DFR] does not have documentation following this to explain why no transfer occurred.  

7 months later, in December 2014 an IHMS medical officer at the Republic of Nauru Hospital (RONH) documents 'advised no operation for tongue tie is indicated. There is clear evidence that tongue tie operation does not improve speech.' Unfortunately, while surgical management of tongue-tie is controversial, indications for possible surgery include articulation problems, psychological problems and periodontal disease—all present in this case. Standard treatment for tongue-tie and speech problems is a collaboration between paediatric ENT specialists with speech pathologists (neither available on Nauru). [DFR] does not have clinical notes between this time and April 2015 when an IHMS psychologist wrote to the Heath Services Manager on Nauru that '(name redacted) had a tongue untied not long ago.'

The psychologist also wrote in 2015 that 'his speech is very poor, due to this he reported being severely bullied by his peers and he is no longer attending school... communication difficulties, enuresis and suffering from bullying reinforced his self-hatred, as a result his self-esteem is non existent in my opinion. Conceptually his sleep deprivation, social exclusion and detention fatigue create more anxiety, severe depression and suicidal ideations...at the moment I worry for his prognosis.' 11 months later, in March 2016 (name redacted) attempted to strike him-self with a knife and Nauru police noted knife slashes on the walls. Upon arrival to hospital (name redacted) stated 'I am tired of life...I want to die.' In May 2016 a psychologist documents '(name redacted) had disclosed suicidal ideations ... he would set himself on fire.'

In April 2016 the Nauru Settlement Clinic child and adolescent psychiatrist had a phone call with a psychiatrist at the RONH who reported 'a psychotic episode' and commenced him on anti-psychotic medication. The psychiatrist writes that he discussed this with the medical team who requested offshore management for close monitoring of suicidal ideation, and treatment by a speech pathologist. No documentation of a transfer request by senior medical officers is found in his file. 

On the 4^th of July 2016 (name redacted) is referred by an IHMS psychiatrist for transfer to Australia or a third country for inpatient treatment ('which has an accessible hospital providing child psychiatric specialist services with capability, expertise and experience with childhood psychosis') of a presumed first episode depressive psychosis (despite this being the second documented event). He writes that (name redacted) 'was found by his father having tried to hang himself from a fan with a computer cord' and hearing voices telling him to kill himself. This referral was updated further on the 7^th of July and the psychiatrist writes that '(name redacted)'s mental condition is reported to have further deteriorated over the last day with ongoing psychotic symptoms...receiving psychiatric care requires time and forward planning to ensure bed availability. IHMS are requesting urgent approval to allow for forward planning of ongoing management.' He was finally transferred to Melbourne on the 9^th of July 2016, three months after the first psychiatrist highlighted suicidal risk and need for inpatient treatment.[140]

2.59      DFR argued that this case study demonstrates a child with a treatable surgical condition and preventable comorbid mental illness, whose care was 'not effectively escalated so that he now suffers severe mental illness with psychosis and is of high suicide risk':[141]

2.60      The committee considers that this is an example of a child with a treatable condition, whose circumstances have presumably worsened because of the lack of timely and appropriate care.

2.61      Like the AMA, DFR raised concerns about the process by which medical records could be obtained, in order to facilitate independent medical scrutiny.[142] It explained that DFR requests medical records from IHMS pursuant to Freedom of Information legislation, and submitted that, 'Frequently these requests are not answered'.[143] It explained that the longest time DFR has waited to receive medical records has been 300 days, with two cases involving a wait of 270 days. It stated that DFR has made 50 complaints to the Office of the Australian Information Commissioner (OAIC) since 30 June 2013. DFR highlighted the following example of a significant delay in receiving a child's medical records:

One of the paediatric cases where [DFR] has not received the clinical file 135 days since the OAIC complaint was made, involves a child with an infectious disease (Schistosoma Japonica) which [DFR] was informed was inadequately treated. The infectious disease poses both a serious risk to the child's growth and the public safety of all those in close contact on Nauru. IHMS has been informed of this and has still not released the medical file.[144]

2.62      IHMS submitted that in each of the complaints which DFR had referred to the OAIC, the Commissioner had found in IHMS' favour.[145]

2.63      DFR also submitted that the department has recently denied a number of requests for medical records on the basis that the signatures on the consent forms did not match the signatures on departmental records. DFR stated that 'it has taken 70 days (10 weeks) for DIBP to review these signatures and inform [DFR] of their concerns'.[146]

2.64      DFR argued that the manner in which healthcare services are provided to patients, particularly suicidal and other at-risk patients, is problematic.[147] It highlighted differences between the care provided to people in Australia who are deemed to be at risk of harming themselves or another person, and the care provided to the same individuals in RPCs. DFR explained that under the Australian mental health legislation, treatment options for patients who are at risk of harming themselves or others include involuntary detention and hospital admission. It also noted that the Mental Health Act 2007 (NSW) 'explicitly outlines that individuals should receive effective care with the least restriction of their liberty, interference with their rights, dignity and self-respect'. It explained that those Australian patients would also have the right to appeal a decision made under the Act, and seek representations from a lawyer, psychiatrist and liaison or advocate. It argued that, by contrast, patients deemed to be at a high risk of self-harming in an RPC are often placed under 24-hour watch by security guards.[148]

2.65      Stanford Law Clinic interviewees echoed concerns about health services in Nauru.[149] They alleged that, at the time of their detention, the Nauru local hospital was unsanitary and had no medical specialists, and that many requests for medical assessment would not be answered for months.[150] One interviewee said that he had been in detention on Nauru for 10 months and suffering from a hand condition. He alleged that the ailment went untreated, his muscles began to wither, and he eventually lost the use of his hand.[151]

Several incident reports in the Nauru files likewise indicate concerns on the part of refugees and asylum seekers about the healthcare services being provided at the Nauru RPC, including a lack of trust in those services. These include allegations of being turned away by health services,[152] allegations of health service workers not providing assistance,[153] and concerns about IHMS showing pregnant families inaccurate images of PNG medical facilities.[154] Several reports indicate particular concerns about women giving birth in Nauru or PNG.[155]

Child welfare and protection

2.66      As set out above, the committee noted extensive allegations of self-harm by children, and allegations of abuse towards children by RPC staff members. The committee also considered further evidence from both primary and secondary sources in relation to the safety and wellbeing of children in the Nauru RPC and the Nauru community.

2.67      In September 2013 there were 173 refugee and asylum seeker children living in Nauru.[156]

2.68      Numerous allegations of improper conduct in relation to children in the Nauru RPC, and of an unsafe environment, have been detailed in evidence presented to the 2014 Australian Human Rights Commission (AHRC) The Forgotten Children report,[157] the 2015 Moss Review,[158] and the 2015 select committee.[159] The select committee concluded that 'the Nauru RPC is neither a safe nor an appropriate environment for children'.[160] The evidence received by this committee is consistent with this conclusion. In both the Nauru RPC, and the wider Nauruan community, the welfare of asylum seeker and refugee children falls well below an acceptable standard.

2.69      Amnesty International submitted that on several occasions, authorities on Nauru have engaged in inappropriate practices in relation to children. It alleged that in 2015 the Nauru Police Force hired a convicted paedophile as a reserve officer, and that a young girl had been questioned by police twice without a child protection specialist having been present.[161]

2.70      In May 2016, the department's Child Protection Panel (Panel) noted concerning incidents involving RPC staff and children. The Panel stated that in 2014 an employee driving a bus with school aged children pulled over, pointed a cricket bat at a teenage boy and told him to shut up and get off the bus. This incident ended when other staff physical intervened and escorted the employee off the bus and removed the bat.[162] The Panel also noted an incident during which a security guard grabbed a child by the hair and collar and dragged them for 20 metres.[163]

2.71      The Panel identified several areas of concern with regard to the involvement of staff in incidents involving children. These included opportunistic assaults on children, (particularly at night),[164] a failure to maintain professional boundaries (including exchanging personal details with children, attempting to connect with them on social media, and making explicit and unwelcome sexual overtures),[165] and staff reportedly under the influence of alcohol or other drugs.[166]

2.72      Several incident reports contained in the Nauru files reflect these concerns, detailing allegations of physical, sexual and emotional abuse against children. These include allegations of physical and emotional abuse by parents towards their own children,[167] fears from parents about not being able to cope and hurting their children,[168] and children asking for their parents not to be told of particular incidents because they would be hit.[169] There are also incident reports detailing parents assaulting other children allegedly because the child in question had hurt their own child.[170] There are also allegations of children assaulting other children,[171] and of sexual assault against children.[172]

2.73      Further incident reports, in addition to those outlined previously, detail allegations of improper conduct by Wilson Security staff members towards children.[173] In one particularly concerning incident, a mother reported that her husband and son had been in a car with a security guard, and that her son said the guard had put his hand up his shorts and played with his bottom.[174] She reported that her husband 'removed [his child] from the middle of the car and placed [redacted] on his lap but did not say anything as he feared the two [security] officers in the car with him'.

2.74      One former teacher on Nauru outlined particular concerns about the care provided to a group of unaccompanied minors.[175] The teacher explained that 29 unaccompanied male children had been transferred to Nauru by February 2014, and were kept in isolated areas of the RPC with restricted mobility. They explained that a number of the boys had self-harmed and attempted suicide while in the 'closed detention environment'.[176] They submitted that in October 2014, the boys were released into the Nauruan community in three separate accommodation complexes, one of which was isolated. The teacher advised that the boys were immediately targeted, and the victims of theft and assault. The teacher also submitted that upon their release into the community, the boys were assured by the Nauruan Government that they would have access to the Nauruan education system. However, the teacher alleged that the boys were barred from enrolling in the local high school. The teacher alleged that despite approaching the department for assistance, 'none of the unaccompanied refugee minors were given the opportunity to obtain high school qualifications'.[177]

2.75      The committee also heard concerns about a widespread lack of school attendance among refugee and asylum seeker children. Amnesty International submitted that when refugee and asylum seeker children were first transferred from the RPC school to the local Nauruan schools the rate of attendance was 60 per cent.[178] HRW submitted that within six months this had fallen to just 5 per cent,[179] with one service provider on Nauru confidentially advising Amnesty International that in September 2016 no refugee or asylum seeker children were attending local schools.[180] Bullying and harassment of refugees and asylum seekers in the local schools by both teachers,[181] and students has been reported.[182] Incident reports indicate that some children have threatened suicide if forced to attend the local schools.[183]

2.76      Incident reports also indicate allegations of inappropriate conduct by local students.[184] In one incident, a child told a Save the Children worker that he and others at Nauru College did not want to attend school because the local boys were touching the girls, and had threatened them with a knife.[185]

2.77      On 4 April 2017, in response to a question from the committee about school attendance in Nauru, the department advised that it does not have any data about the rates of school attendance at local Nauruan schools. It stated that:

The full integration of asylum seeker and refugee children in the local education system was agreed between the Department and the Government of Nauru in May 2015. This integration was designed to facilitate greater self-agency; and promote social connectedness for refugee and asylum seeker children and their families with the local community.

School attendance data is therefore a matter for the Government of Nauru.[186]

2.78      The department advised that it would send a request to the Government of Nauru for information about school attendance rates.[187]

2.79      The department also explained that it has expended $8.4 million constructing a new facility at the Nauru Primary School, and has a contract with the Brisbane Catholic Education Office (BCEO) to provide education services on Nauru, at a total cost of $10 million.[188]

Papua New Guinea

2.80      While the committee heard a number of concerns about the Manus Island RPC, there is less information available when compared to the Nauru RPC.  

RPC conditions

2.81      The committee heard evidence concerning the suitability of facilities and services at the Manus RPC, as well as allegations of widespread poor mental health, poor health services, and a lack of safety in the PNG community. The suitability of facilities and services at the Manus Island RPC were also discussed extensively by this committee in December 2014.[189]

2.82      As set out in Chapter 1, since April 2016 the Manus RPC has been described as being an 'open centre',[190] and in March 2017 was declared to already be 'closed',[191] (despite the fact that it is still operating, and the contracts of service with Broadspectrum, IHMS, Wilson Security and other contractors are still operational).  

2.83      However, the UNHCR submitted that overcrowding, a high number of guards, perimeter fences, and the use of communal tents means that the conditions in the RPC remain indistinguishable from the previous detention arrangement.[192] It reported that when it visited the Oscar and Delta compounds of the RPC in April 2016, recognised refugees were allocated just 1.68 square metres per person—being half the minimum amount of space required under international prison standards.[193] It cautioned that the risks to public health and mental health in these conditions were 'considerable', and submitted that the lack of personal space increased the possibility of abuse.[194]

2.84      Stanford Law Clinic interviewees echoed these concerns about a lack of space, alleging that staff members had crowded 50 people into one tent.[195] One interviewee alleged that, while most men were required to sleep in bunk beds, the top bunk was so close to the roof of the tent that it would press against the ceiling and get so hot that most men would simply sleep on the floor.[196] The men also described food rotting quickly in the high heat, and the infestation of food with insects.[197] These claims reflect similar evidence presented to the committee in December 2014.[198] Interviewees also alleged that websites were blocked within the RPC, including blocking of websites which would offer legal services.[199]

High levels of self-harm and poor mental health

2.85      The committee heard strong evidence indicating that asylum seekers and refugees in PNG experience poor mental health at an extremely high rate, and that rates of self-harm are similarly high.

2.86      HRW explained that when it visited the Manus RPC in 2015 it met individuals who cut themselves, hit their head against the wall, refused to go outside, and refused to speak to others for months.[200] When the UNHCR visited later in
April 2016, its medical experts interviewed 181 asylum seekers and refugees (being 76.8 per cent refugees).[201] At the time of the study, the median period of time in detention was 31 months.[202] The UNHCR found that 88 per cent of interviewees suffered from a depressive, anxiety and/or Post Traumatic Stress Disorder (PTSD),[203] and described the prevalence and severity of mental disorders among the refugee and asylum seeker population as 'extreme',[204] commenting that:

The rates of caseness for depressive or anxiety disorders and/or PTSD in the asylum-seeker and refugee population in the Manus Island RPC or ELTC are amongst the highest recorded rates of any surveyed population. They are many-fold higher than in mainstream Australian populations and higher than that recorded in asylum-seeker populations living in the Australian community.[205]

Healthcare facilities and services

2.87      The committee heard evidence of serious concerns about the adequacy of health care services available to refugees and asylum seekers in PNG. Many of these concerns were reported on by this committee in December 2014.[206]

2.88      Both the AMA and DFR raised a number of concerns about health care treatment based on health records which they had scrutinised.

2.89      For example, the AMA provided a number of, what it described as, concerning case studies from patients on Manus.[207] These included:

• a 70 year old Rohingya asylum seeker detained in the Manus RPC was a patient in the Port Moresby Hospital for seven months, where he received little treatment. He had been diagnosed with a heart condition and high blood pressure, with symptoms including swollen feet and legs, and an inability to walk or stand for longer than a few minutes. He was then returned to the RPC and waited 20 days for a doctor's appointment. The AMA advised the department's Chief Medical Officer Dr Brayley, that without treatment the patient was likely to die. The AMA was subsequently advised that a request for the man's medical transfer to Australia 'should have been put in train last week by IHMS'. At the date of writing the submission the AMA stated that it was not aware of where the man was located or any other details about his care.[208]
• a man who had undergone testing at the Port Moresby Hospital was returned to the Manus RPC because the hospital did not have the facilities to treat the patient further. The AMA was advised that a neurosurgeon had advised that the patient would require a blood test which could only be completed in Australia, as well as an investigation by a neurosurgeon. The AMA stated that it had been confidentially advised that the patient was provided with a teleconference with an endocrinologist located in Australia who, having not seen any of the patient's medical records and without asking him to explain his symptoms, prescribed the patient a twice weekly medication for two years.[209]
• a man allegedly sustained a head injury at the Manus RPC, and subsequently lost consciousness twice over the following 38 hours.[210] The AMA stated that a neurosurgeon advised that the patient required a brain scan and possibly an MRI. The AMA stated that the department advised it that the patient 'is not prescribed any regular medications [and] no recent health issues have arisen'.

2.90      DFR raised similar concerns in relation to a number of cases of which it was aware:

• a man who arrived in the Manus RPC with no documented pre-existing physical or mental illness who presented, over the following two years, with intermittent concerns about deteriorating health, including untreated dental pain, undiagnosed hand pain, and worries about his family back home. In August 2015 he was transferred to the transit centre and saw a series of doctors 'without formal diagnoses made for his physical ailments'. In May 2016 a psychiatrist recorded that he 'now suffers from reactive depression with self-harm intent'. An advocate made a referral to DFR on 17 May 2016, because the man had expressed a desire to self-immolate. On 26 May an urgent request was sent to IHMS for his medical file. DFR made multiple attempts to access his file, and then made a complaint to the OAIC pursuant to Freedom of Information Act 1982. After making the complaint, DFR received the man's medical file on 25 July 2016. The last documentations on the file following the psychiatrists report in May, were entries from 2 June to 14 July, where 'the mental health team report he did not attend his appointments'. DFR stated that 'there is no documented effort made by health workers to determine why despite a high risk of suicide'.[211]
• a man who developed PTSD following the Manus RPC riots in February 2014, and who witnessed the murder of Mr Reza Barati and was himself assaulted, developed nocturnal enuresis. DFR stated that this was attributed to the man's PTSD, and no investigation into possibly organic causes was conducted. DFR stated that in November 2015, an attending IHMS doctor noted a plan to arrange a urology teleconference. An external referral for a urology review was completed on 5 December 2015. DFR stated that, according to the man's medical record, 'he has not received further specialist assessment despite recommendations by IHMS doctors'.[212]
• a man in PNG was experiencing chronic back pain. In 2015, an MRI indicated a 'significant abnormality'. A neurosurgeon recommended surgical treatment. On 22 February 2015 an Australian neurosurgeon recorded that he had discussed the man's situation with 'senior Neurology colleagues' in Melbourne, as well as 'senior administration'. He recorded that they were 'happy to provide the requisite high level of care needed' by the man given his 'medical and surgical circumstance'. DFR stated that it has been advised that the man did not receive surgery. DFR also stated that it requested the man's medical file in June 2016, and this request was rejected by the department on the basis that a signature was missing 'on a portion of the form unrelated to his consent'. DFR stated that it sought legal advice, that indicated the initial consent form was adequate under FOI laws. It stated that a further consent form was sent in August. It advised that three months later, in November, the records were received, however they only documented the man's records up to December 2015.[213]

2.91      Stanford Law Clinic interviewees made similar allegations of wide ranging health problems, including widespread depression, physical degradation, weight loss and constant pain.[214] One described the poor treatment he received after contracting malaria,[215] and another described a spinal injury which he suffered in the riots of 2014, which he explained had impacted the use of his hands, and would limit his mobility and career prospects.[216]

2.92      There have also been a number of deaths at the Manus RPC. In February 2014, Mr Reza Barati (aged 23) was beaten to death in the RPC by RPC staff members during a riot. His death was the subject of a substantial inquiry by the committee.[217] In August 2014, Mr Hamid Khazei (aged 24) died after having presented to the Manus Island medical clinic with a fever and chills. He had been first evacuated to Port Moresby for treatment, and then to Australia, where he died. His death is currently the subject of an inquest in the Queensland Coroner's Court. On 22 December 2016, Mr Faysal Ishak Ahmed (aged 27) collapsed in the Manus RPC. He was evacuated to Australia for treatment on Friday 23 December, and died the following day. Mr Ishak Ahmed's death is also the subject of an inquest in the Queensland Coroner's Court.[218]

2.93      The department stated that Mr Ishak Ahmed had died 'from injuries suffered after a fall and seizure'.[219] There are, however, reports that Mr Ishak Ahmed had been unwell for some time. Mr Behrouz Boochani, an Iranian refugee on Manus Island, posted to Facebook on 23 December 2016:

Just now a plane took an injured Sudanese refugee to Australia. He was so sick for more than six months and IHMS did not care about his pain. Last night he collapsed in Oscar prison and injured his head seriously, it was not the first time that he had fainted. A few days ago the refugees wrote a complaint against IHMS about his situation.[220]

2.94      The following day, having been advised of Mr Ishak Ahmed's death, Mr Boochani posted:

Faysal wrote about his heart problem and headaches. Many times Faysal collapsed and all of us here knew that he was seriously sick for more than 6 months. More than 60 people wrote a letter to IHMS and explained to them how Faysal is sick and has constant headache and heart problem but they did not care. Every day Faysal went to medical asking for help. They did not help him. A few days ago a nurse in IHMS told Faysal that he was fine and didn't need medical treatment.[221]

2.95      Another detainee, Mr Abdul Aziz Adam, was reported to have said that Mr Ishak Ahmed sought treatment every few days for ailments including stomach upsets, high blood pressure, fevers and heart problems, and that the staff would tell him 'you don't have anything'.[222]

2.96      The department advised the committee that a medical evacuation by Air Ambulance was recommended for Mr Ishak Ahmed at 1.10 am on 23 December 2016, and that Air Ambulance landed in Brisbane with Mr Ishak Ahmed at 11.36 pm that night.[223]

2.97      As discussed above, the UNHCR visited the Manus RPC in in April 2016 to conduct a mental health study, which concluded that the prevalence and severity of mental disorders was extreme.[224] It stated that this study found that individuals who had previously sought medical treatment were finding the services to be unhelpful, and were disengaging.[225] It also stated that individuals indicated that the Overseas Services to Survivors of Torture and Trauma (OSTT) service was helpful, but only a small number of people could receive treatment because of capacity constraints.[226]

2.98      The UNHCR submitted that individuals who went untreated would experience 'significant morbidity and potentially mortality from suicide and it is likely will require considerable treatment to regain premorbid levels of functioning'. It argued that 'it is not apparent that currently health services recognise or are adequately treating these patients placing them at further risk of deterioration'.[227] It also advised that 'such treatment services do not exist within the mainstream PNG health system':

[T]he type, extent and severity of these mental disorders is unprecedented within the Papua New Guinea health system...Papua New Guinea mental health services are structured to assess and treat low prevalence illnesses such as schizophrenia, bipolar disorder and substance related disorders. There is no current skills capacity within Papua New Guinea public mental health services to address severe-post traumatic stress disorder and current resourcing will not be able to cope with the surge of cases with major depression.[228]

Conduct of RPC staff

2.99      The committee heard allegations about abusive and improper conduct on the part of Manus RPC staff. Allegations of unlawful and improper conduct on the part of staff members were also outlined extensively by the committee in December 2014, in its inquiry into the matters surrounding riots in the Manus RPC in February 2014.[229]

2.100         The department explained that there are currently two service providers engaged by the department to provide services at the Manus RPC: Broadspectrum (which is contracted to provide garrison and welfare services until 31 October 2017), and IHMS (which is contracted to provide health services until 30 June 2017).[230] Wilson Security then provides its own services and subcontacts to three further local providers. It advised that at 7 November 2016, it directly employed 283 expatriate safety and security personnel, and through subcontracting arrangements with three local security service providers, indirectly engaged 569 local personnel.[231]

2.101         Ms Jessica Bloom, a former employee on the RPC, submitted to the committee that, in her experience, any staff members who deviated from using language which dehumanised the detainees was 'instantly suspect' and would be questioned and monitored by others for not having 'professional boundaries'.[232] She stated that despite attempts by management to ensure that staff referred to detainees by their names, they would generally be referred to by their boat identification number.[233] She also alleged that refugees and asylum seekers would be taunted, provoked and humiliated by Australian staff members,[234] pushed and subjected to verbal abuse including calling them 'rag heads' and 'sand niggers',[235] and physically crowded by guards and sexually assaulted. [236]

2.102         The UNHCR similarly submitted that refugees and asylum seekers in PNG are the victims of bullying, intimidation and harassment.[237] It explained that when its experts visited the Manus RPC in April 2016, most of the men interviewed described the impact of witnessing or having been involved in the assaults on refugees and asylum seekers at the RPC in 2014:

They described these experiences as 'terrifying' and 'horrific', resulting directly in post-traumatic stress disorder or catalysing pre-existing traumatic memories into post-traumatic stress disorder according to the medical experts.[238]

2.103         It explained that the medical experts had noted that a significant number of asylum seekers and refugees reported experiences of bullying and intimidation from staff members, which 'has resulted in them being frightened, withdrawn and submissive in their interactions' with staff.[239]

2.104         Interviewees of the Stanford Law Clinic likewise made allegations of physical abuse from staff members. Interviewees alleged that during the Manus RPC riots a man had been kicked repeatedly in the back causing his disks to fracture, and another man being beaten so severely on his arm that a bicep muscle broke.[240] Another interviewee alleged that guards would punch and hit refugees and asylum seekers held in detention, without consequence.[241] Dr Barri Phatarfod of DFR, and Dr Steven Faux, described to the Clinic the case of a man with a broken cheekbone, who had been refused medical treatment for a number of days, which resulted in the—easily preventable—loss of his eye.[242]

2.105         The department submitted that there is no evidence that the practice of referring to asylum seekers by their boat identification number 'exists currently'. It stated that a service provider had apologised for doing this, and asserted that the practice has not reoccurred.[243]

Safety in the local community

2.106         The committee heard evidence of concerns about the safety of refugees and asylum seekers on Manus Island, and the wider PNG communities.

2.107         HRW submitted that refugees and asylum seekers in PNG are very concerned for their safety, and rarely leave the Centre despite now having the freedom to do so.[244] It also submitted that these fears were contributing to an unwillingness to consider settling in PNG, with some refugees describing settling in PNG as 'unthinkable' and 'terrifying'.[245]

2.108         Mr Daniel Webb of the HRLC witnessed a violent attack against two Afghan Hazara refugees on Manus Island, one of whom was beaten until he fell unconscious.[246] Ms Elaine Pearson of HRW submitted that several of the 25 refugees who had moved to mainland PNG to work and live, had returned to Manus because they felt unsafe, were the victims of crime, or faced problems in the workplace.[247] One man reportedly became homeless after settling in mainland PNG.[248] HRW also submitted that refugees and asylum seekers on Manus Island are not allowed to engage in paid employment there, because PNG officials had only agreed to host the detention centre there, not integrate refugees.[249]

2.109         HRW also highlighted discrimination against gay asylum seekers and refugees, arguing that they are shunned, and have been subjected to assault and sexual abuse.[250] Same-sex relationships between men are a criminal offence in PNG, being categorised as acts of 'gross indecency', punishable by imprisonment for up to three years.[251] PNG law also criminalises all sexual acts which are 'against the order of nature', the maximum penalty for which is imprisonment for up to 14 years.[252]  

2.110         The committee also noted a number of widely reported incidents indicating instances of neglect among refugees living in local PNG communities.

2.111         On 19 February 2016, it was reported that a young refugee named Mr Loghman Sawari, who had left the Manus RPC, had faced serious difficulties living in the local community.[253] Mr Sawari, who had originally been wrongly transported to Manus Island as an unaccompanied minor, was reported to have been one of the first refugees to be released from RPC detention. It was reported that he moved to Lae (the second largest city in PNG),[254] and provided with a construction job and housing.[255] It was reported that Mr Sawari's employment and housing did not last, and he was found to be sleeping rough on the streets of the city. Mr Sawari reportedly alleged that he had been paid less than other workers, and that the medical expenses which he had been promised as part of his resettlement were not provided. One month later, it was reported that Mr Sawari had been taken into police custody for trying to climb the fence to return to the Manus transit centre, after having been refused re-entry to the centre.[256] Mr Sawari reportedly advised that the following morning, PNG immigration officials offered to help him return to his home country.

Phosphate mining and cadmium exposure in Nauru

2.112         The committee received evidence of concerns about the implications of exposure to phosphate mining in Nauru, including exposure to cadmium.[257]

2.113         As set out in previous inquiries, the Nauruan environment was damaged by extensive phosphate mining throughout the twentieth century. In 2013, the Nauruan Government explained that phosphate mining had had serious impacts on the community:

In addition to the damage done to the land surface, the mining has created its own pollution, particularly cadmium residue and phosphate dust. The pollutants from the mine have infiltrated into the natural environment of Nauru. The phosphate dust pollutes the air and reduces the quality of water in certain residential areas which has had a negative impact on health.

The environmental disaster caused by the mining impacts all sectors of development. Rehabilitation of the mined phosphate lands is a prerequisite for improving food and water security and the well being of the people of Nauru.[258]

2.114         The Nauru RPC sits at the centre of a phosphate plateau, and is surrounded by ongoing phosphate mining operations.

2.115         Cadmium is an element found in the earth's crust and, to a lesser extent, in rocks and soil. The World Health Organisation (WHO) classifies cadmium as a human carcinogen, which has toxic effects on the kidneys, and the skeletal and respiratory systems.[259] It explains that cadmium can be ingested through the consumption of contaminated foods, and inhaled by workers 'in the non-ferrous metal industry'.[260] WHO also notes that in the human body cadmium has a half-life of between 10 and 35 years, and that accumulation of cadmium in the body may lead to:

• (generally irreversible) renal tubular dysfunction;
• disturbances in calcium metabolism and the formation of kidney stones;
• the possible development of Itai-Itai disease (which is characterised by osteomalacia, osteoporosis, the fracture of bones, and kidney dysfunction);
• potentially lethal acute pneumonitis with pulmonary oedema;
• potentially chronic obstructive airway disease;
• lung cancer; and/or
• the potential development of cancers of the kidney and prostate.[261]

2.116         The WHO recommended a number of measures to decrease exposure to cadmium, including ensuring that cadmium emissions from mining and the use of phosphate fertilizers and cadmium-containing manure be reduced as far as possible.[262]

2.117         In 2005, Professor John Morrison and Dr Harley Manner conducted a study of Nauruan soil.[263] This study explained that approximately 100 million tonnes of phosphate material has been removed from the Nauru atoll, leaving over 80 per cent of the island 'a dolomite pinnacle-dominated karrenfeld'.[264] The study found that cadmium levels in Nauruan soil were 'well above global averages’.[265]

2.118         In 2012, the department commissioned an environmental due diligence report to be prepared in relation to Nauru.[266] On 24 July 2014, this report was partially published pursuant to a Freedom of Information request.[267] The report, prepared by Sinclair Knight Mertz (SKM), assessed only the topside, black soil and staff housing sites on the island.[268] It noted that:

• a report commissioned by the Republic of Nauru in 1996 found that 'further studies need to be carried out regarding the extent of the threat of cadmium disposal to human health and the environment';[269]
• in 2004, the Republic of Nauru had identified cadmium sludge as a threat to the quality of groundwater resources, among other threats including metals associated with blasting and mining, asbestos, ordinance compounds and other materials associated with historical bombing, and sewage overflow;[270] and
• phosphate dust including cadmium was at risk of being deposited into clean water storage or storm water drains, or inhaled, contributing to possible health risks;[271]

2.119         SKM recommended that the department maximise 'separation between sources of phosphate dust emissions and habitable areas within the regional processing centres and consider planting tall vegetative screening around project sites'.[272]

2.120         SKM also highlighted the inadequacy of waste management infrastructure in Nauru at the time of the assessment, stating that this:

...combined with extensive cavities associated with the karstic limestone landform is likely to have contributed to uncontrolled disposal of wastes, including potentially hazardous wastes such as asbestos building materials, fuels, oils, grease and possibly mining wastes (e.g. cadmium sludge). The type, quantity and location of such wastes is unknown but the presence of such wastes within the project sites cannot be ruled out at this stage.[273]

2.121         IHMS advised the committee that it had raised the question of cadmium exposure with the department. Dr Kalesh Seevnarain, Senior Health Adviser with IHMS, stated that IHMS had been made aware of 'high levels of cadmium on Nauru', and had been engaging with the department over the past few months in relation to this.[274] He explained that IHMS' recommendation to the department 'would have been to further investigate what those levels really are and to then understand what the impact might be on health'.[275] He also confirmed that a recommendation had been made to the department in relation to this.

2.122         The department characterised this contact as IHMS having provided 'information about the risk of cadmium exposure to human health', and stated that IHMS had advised that they were not aware of any environmental threat from cadmium to the 'island population'.[276]

2.123         The department submitted that 'Management of cadmium risks across the island is a matter for the Government of Nauru. The Department has no legal authority to act on this'.[277] It also stated that in relation to the RPC it had incorporated 'dust suppression' measures in its construction program, and noted that domestic water on Nauru is provided via reverse osmosis of sea water, thereby alleviating the risk of cadmium contamination via water.[278]

2.124         The committee received evidence of refugee housing located immediately adjacent to active phosphate mining activities.[279] The committee asked the department whether any refugee or asylum seeker accommodation facilities, or any other RPC facilities, are located near active mining operations in Nauru. The department responded that no 'regional processing facilities' are located within the 'immediate vicinity of any active mining operations'.[280]

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