The desperate state of healthcare offered to asylum-seeker families, children, babies and pregnant women inside the Nauru detention centre can be revealed for the first time in a comprehensive report produced by five independent clinical experts, obtained exclusively by Guardian Australia.



Observations in the report include:

Children in the Nauru detention centre are not adequately screened for disease, resulting in the likelihood that many are carrying undiagnosed blood-borne diseases and up to 50% are carrying latent tuberculosis.

There are no paediatricians employed in the centre and no paediatric life support available on Nauru.

There is no clear child protection framework for children inside the centre and it is unclear what child protection checks are undertaken for Nauruan staff. This, according to the report, “places them [asylum seeker children] at significant risk of sexual abuse”.

Most pregnant women are suffering from depression.

Immunisation courses are not properly completed, increasing the risk of transferable diseases.

In a 14-month period between 2012 and 2013 there were 102 cases of self-harm, including 28 hanging attempts by 18 detainees; 6.3% of the asylum seekers are on psychotropic medication to treat mental illness.

There were 53 medical transfers to Australia in 2012-13 at a cost of $85,000 a transfer, with the report also noting that these can take up to 36 hours to complete.

Living conditions are “crowded, hot and humid” with children having “limited meaningful play”. Children play with stones.

There is an apparent significant risk of groundwater

contamination as a result of poor waste management at the detention centre.

There are nine 17-year-old unaccompanied minors on Nauru

The 56-page document, completed by the “physical and mental health subcommittee of the joint advisory committee for Nauru regional processing arrangements”, was not meant for public consumption and was filed for review to the Nauruan and Australian governments, who chair the committee.

It outlines substantial problems created by the Coalition government's rapid offshore transfer policy for asylum seekers and was written after a site visit to Nauru in February.

The report raises many issues similar to those expressed in a letter of concern signed by 15 doctors working in detention centres on Christmas Island and reported by Guardian Australia in December. The report notes asylum seekers on Nauru often queue for an hour a day to receive medical attention and records criticisms of the prescription process and IT systems that are similar to those described in the 92-page Christmas Island letter.

The revelations follow serious allegations of assault against child asylum seekers in detention on Nauru in March, which raised further questions about the safety of children in detention.

It is understood that many of the 18 recommendations noted by the independent experts are being considered by both the Nauruan and Australian governments but the health subcommittee does not have the power to enforce any of its findings.

A spokeswoman for the immigration minister, Scott Morrison, did not respond to detailed questions but said: "The majority of recommendations in the report were supported by the department and either already acted upon or subject to planned service improvements as identified by the department’s chief medical officer."

She did not say which of the recommendations had been acted upon.

Guardian Australia understands that many of the issues articulated in the report are still current.

The report raises concerns similar to those expressed by doctors in detention centres on Christmas Island

‘Critical issues’ with child health screening and medical facilities

Children under 15 do not receive blood testing, meaning there is “extremely limited screening for communicable/infectious diseases”, according to the report. Children are not examined for mental health issues and IHMS, the private medical provider running services in detention, does not employ a paediatrician.

The report notes a “lack of resuscitation support for infants and children” in the centre and states that there is just one paediatrician employed by the island’s only hospital who speaks “minimal English”.

There are now 190 children detained on Nauru.

The subcommittee was also unable to verify if children detained on Nauru had been health screened at all before being transferred from Christmas Island under the government’s “rapid transfer” policy, which mandates that asylum seekers are moved offshore within 48 hours.

“The lack of child health screening in detention healthcare (overall and prior to transfer) means the physical and mental health conditions are likely to emerge in children after transfer and communicable diseases and developmental issues will remain unaddressed,” the report says.

It adds that pathology results for any child who is screened on Christmas Island are unlikely to be available owing to the rapid transfer. Medical groups have strongly criticised this policy.

The report notes there are no facilities for blood culture tests in the centre. “The evacuation time [from Nauru to Australia] is reported to be 24-36 hours, during which time an acutely unwell neonate [newly born baby] would deteriorate and could die,” the report states.

The report notes it is likely that up to 50% of children have latent tuberculosis, with “their risk of developing active tuberculosis increased by young age, recent migration and social stressors, all of which are relevant in this setting”. The report adds that multiple children will have undiagnosed blood-borne diseases, including hepatitis B.

It states that the care available for children and newborns is “not in keeping with an Australian community standard of care” and there is no memorandum of understanding in place with the hospital on Nauru despite the fact it provides a backup to the detention centre in complex cases.

“To put this in perspective, a hospital with around 20-30 staff on a given day that serves a local population of 10,000 people is providing backup to a health centre with around 50 staff on a given day, that provides healthcare to 2,300 people,” the report says. “It is unclear how use of the RoN [Republic of Nauru] hospital by people from the RPC [regional processing centre] affects local access to care, including to resources such as neonatal care, dental care and optometry services.”

Guardian Australia submitted detailed questions to IHMS, the private medical service provider. It declined to comment.

Child protection ‘a major concern’

There is no clear child protection framework in the detention centre. While service provider have “measures” to perform police checks or working-with-children checks on Australian staff, there are inconsistent requirements across agencies. It is also unclear what checks local staff, who constitute 53% of the workforce, have to undergo.



“Detention, and the grouping of large numbers of children and adults in crowded living conditions, without normal social structures or activities, risks exposing children to physical and mental violence and places them at significant risk of sexual abuse,” the report notes, adding that unaccompanied minors are at particular risk.

The report says that not a single stakeholder in the centre has a clear child protection policy in place and adds that unaccompanied minors, whose legal guardian duties are enacted by a Save the Children manager, have no clear framework to report abuse:

“... it was unclear how decision-making or acting in ‘best interests’ might occur [for unaccompanied minors], what legal training had been undertaken, which legal framework would be utilised, whether the organisation had protocols for management and decision making in sentinel events (eg sexual assault) and whether there was a plan for long-term review and support of children’s rights.”

The report says service providers reported they would refer child protection issues to the Nauru police, but adds: “Nauru does not have a child protection framework.”

Guardian Australia contacted all service providers in the detention centre asking them to detail their policies on child protection. A spokesman for Transfield Services, which manages the detention centres on Nauru, said all Australian staff were assessed by the Australian federal police before working in the centre. The spokesman said all Nauruan staff “undergo a Nauru police check and sign a statutory declaration. They are also trained in the DIBP’s [Department for Immigration and Border Protection] protocols for handling children.” The spokesman said other checks were carried out but declined to go into detail as to what they were.

A spokesman for Save the Children, which provides childcare in the centre, said child protection was the organisation’s “No 1 priority” on Nauru.

“A child safeguarding protocol and code of conduct prepared by Save the Children is in place on Nauru and is mandatory for all service providers. It outlines child-safe recruitment techniques, including working with children checks and/or police checks for positions involving contact with children, and detailed incident reporting and investigation procedures.”

The spokesman said all Save the Children staff – Australian and Nauruan – were required to undergo police or working-with-children checks and sign a code of conduct.

With regards to the subcommittee’s observations on Save the Children’s guardianship role for unaccompanied minors, a spokesman said: “The manager and all staff responsible for the supervision of unaccompanied minors are trained on the decision-making processes and reporting procedures. All incidents are reported in accordance with the regional processing centre guidelines and the protocol.”

Seven cases of self-harm a month and high rates of depression among pregnant women

The report describes a “critical issue” of self-harm with an average of seven episodes each month between September 2012 and November 2013.

In that period there were 28 attempted hangings and five attempts at throat slitting. Twelve asylum seekers made more than one attempt at self-harm; 10 of those people had escalating histories.

Sixty adults were taking psychotropic medications at the time of the visit, constituting 6.3% of the detention centre’s population.

Thirty-three of the 53 medical transfers off Nauru in 2012-13 were related to mental health issues.

There were 15 pregnant women on Nauru at the time of the visit, with five who had been transferred to Australia for care. Mental health staff reported that most pregnant women had “consistently high” scores of depression on the Edinburgh postnatal depression scale. “Most women scored around 24, where the cut point for detecting significant depression is 10,” the report says.

The report also notes there is no facility for advanced paediatric life support at the Nauru hospital and only one incubator. Women experiencing pregnancy complications are transferred to Australia to give birth.

The spokeswoman for Morrison was asked whether the government would abandon its rapid-transfer policy. She said: “There have been no recent rapid transfers to offshore processing centres. There has not been a successful people smuggling venture to Australia in almost six months.

“Transfers are occurring in a planned schedule that take into account any matters that have to be addressed.

“There has been no change to government policy since the commencement of Operation Sovereign Borders and the government is not considering any changes to these policies.”

The report contains many more details about the state of healthcare provisions inside the detention centre. Guardian Australia has published it in full here. The report was not given to Guardian Australia by any members of the subcommittee and none wished to comment.

