10. Physical Health of Children in Immigration Detention

A last resort?

National Inquiry into Children in Immigration Detention

• Back to contents

 

10. Physical Health of Children in Immigration Detention

The human right to health is not simply the right to health care. It is also a right to the underlying determinants of health, including food and nutrition, housing, access to safe drinking water and adequate sanitation, and a healthy environment.

Special Rapporteur on the right to the enjoyment of the highest attainable standards of physical and mental health⁽¹⁾

Health is clearly an issue of great importance to children and their parents. The Convention on the Rights of the Child (CRC) appropriately places a high obligation on all nations to ensure that children can enjoy the 'highest attainable standard of health'.

The overwhelming number of health issues about which the Inquiry received evidence related to psychological rather than physical problems (see further Chapter 9 on Mental Health). Furthermore, many of the physical problems identified were in fact a manifestation of the decline in children's mental health - for instance self-harming actions.

However, it became apparent during the course of the Inquiry that, despite the efforts of individual staff members, the detention of children in remote facilities posed some barriers to ensuring the provision of the highest attainable standard of health for children detained in those facilities for long periods of time. Furthermore, an independent review of health services in detention over 2001 (the Bollen Report) noted several shortcomings in the system in place to provide health service to detainees.

This chapter therefore addresses the following questions:

10.1 What are children's rights regarding physical health in immigration detention?

10.2 What policies were in place to ensure the physical health of children in detention?

10.3 Did children enjoy a healthy environment in detention?

10.4 What health care services were available to children in detention?

There is a summary of the Inquiry's findings at the end of the chapter.

10.1 What are children's rights regarding physical health in immigration detention?

The CRC requires the Commonwealth to ensure that all children within Australia can enjoy 'the highest attainable standard' of health that Australia can offer. The Commonwealth must also ensure that no child in Australia is deprived of access to the health care services necessary to achieve that standard.

States Parties recognise the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.

Convention on the Rights of the Child, article 24(1)

The right to access the health care services available in Australia applies to all children whether or not they are in detention. However, unlike children and parents in the community, families in detention cannot decide where they live, have very limited ability to decide what they eat or wear, and have no ability to seek out their chosen doctor or hospital. There is therefore an obligation on the Commonwealth to take positive measures to ensure that children live in a healthy environment and have equality of access to the health care services available to other children in Australia with similar needs, because this is the 'highest attainable standard' in Australia.

Article 24(2) provides a non-exclusive list of how the 'highest attainable standard of health' may be achieved including the provision of primary health care, combating disease and malnutrition by providing adequate nutritious foods and clean drinking-water, and prenatal and postnatal health care for mothers. This is generally reflective of the core obligations of the right to health as set out by the United Nations Committee on Economic Social and Cultural Rights.⁽²⁾ Article 25 of the CRC requires periodic review of the health care provided to children.

Article 39 also requires Australia 'to take all appropriate measures to promote physical recovery and reintegration ....in an environment which fosters the health, self-respect and dignity of the child'.

The United Nations Rules for the Protection of Juveniles Deprived of their Liberty (the JDL Rules) generally reflect what should be done to protect the 'health and human dignity' (rule 31) for juveniles in detention. For example, rules 33-34 talk about the importance of ensuring appropriate sleeping accommodation and sanitary facilities and rules 36-37 set out the importance of appropriate clothing for the climate and suitable food. Rule 49 states that all children should receive 'adequate medical care, both preventative and remedial, including dental, ophthalmological and mental health care'. It also states that all medical care to children in detention should, where possible, 'be provided to juveniles through the appropriate health facilities and services of the community in which the detention facility is located'.

Rule 50 states that children should 'be examined by a physician immediately upon admission to a detention facility, for the purpose of recording any evidence of prior ill-treatment and identifying any physical or mental condition requiring medical attention'. Rule 51 states that the medical service should seek 'to detect and should treat any physical or mental illness' and that there be 'immediate access to adequate medical facilities and equipment appropriate to the number and requirements of its residents'. Rule 51 also states that all children should be 'examined promptly by a medical officer' where there are health concerns and rule 52 states that medical officers should notify the detention authorities if a child's physical or mental health 'will be injuriously affected by continued detention, a hunger strike or any condition of detention'.

Compliance with these rules provides some guidance as to whether Australia is satisfying its obligation to provide 'the highest attainable standard of health' as well as the obligation to ensure respect for the inherent dignity of children in detention under article 37(c) of the CRC.⁽³⁾

Certain groups of children require special attention to their health needs due to their particular vulnerability. Article 22(1) of the CRC requires Australia to provide appropriate assistance to asylum-seeking and refugee children, to ensure that they can enjoy their right to 'the highest attainable standard of health'. They may also need additional assistance to enjoy their right to an environment that fosters the maximum possible development and recovery from past trauma (articles 6(2) and 39). For example, children in detention may require additional services to assess and treat, amongst other things, the effects of nutritional deprivation, exposure to diseases not commonly seen in Australia, injuries that may not have been treated properly, the effects of armed conflict, and extensive travel in unfavourable and stressful conditions. Some health issues likely to face child refugees are described by the United Nations High Commissioner for Refugees (UNHCR) in Refugee Children: Guidelines on Protection and Care.⁽⁴⁾

Further, international law emphasises the particular health rights of girls and women, due to the discrimination they often suffer in accessing nutrition and health care services, as well as their particular health needs. Compliance with article 12 of the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) requires Australia to take all appropriate measures to eliminate discrimination against women, including girls and adolescents, in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services. Special attention should be given to the health needs and rights of women belonging to vulnerable groups such as refugee women and children.⁽⁵⁾ CEDAW also requires Australia to ensure women receive appropriate services in connection with pregnancy, confinement and the postnatal period, as well as adequate nutrition during pregnancy and lactation. As mentioned above, article 24 of the CRC also recognises the importance of ensuring that pregnant women receive adequate health care for the health of children.

Given the importance of health to children and their parents, Australia's obligation to ensure that the best interests of the child are a primary consideration (article 3(1), CRC) should include health considerations. Therefore in order to satisfy article 3(1), the Commonwealth legislature and executive should directly consider whether, and how, the long-term detention of children is capable of achieving the required level of health care, keeping in mind the remoteness of some of the facilities and the special health care needs of many asylum-seeking children.

10.2 What policies were in place to ensure the physical health of children in detention?

Australia is responsible for ensuring that the health care needs of children in detention are met in compliance with our international obligations. This responsibility is primarily executed through the actions of the Department of Immigration and Multicultural and Indigenous Affairs (the Department or DIMIA). However, over the period of the Inquiry the Department contracted much of the day-to-day provision to Australasian Correctional Management Pty Limited (ACM).

10.2.1 Department policy on health for children in detention

The Department's submission recognises its duty of care in relation to the health of detainees and states that the duty is discharged by:

meeting obligations under relevant Commonwealth, State and Territory legislation and implementing Commonwealth and Departmental policies in relation to health care.⁽⁶⁾

The Immigration Detention Standards (IDS) incorporated into the contract with ACM suggest that the legislation being referred to includes the Commonwealth quarantine legislation and State public health legislation.⁽⁷⁾ The Department may also be referring to State child welfare legislation,⁽⁸⁾ and State standards for the provision of services in juvenile prisons.⁽⁹⁾

The Department also created a handbook to assist Departmental Managers of detention facilities (the Handbook) which elaborates on the IDS. The Handbook recognises that the health care facilities and services must be 'equivalent to the standard available to the wider Australian community'.⁽¹⁰⁾ Moreover, the Department's submission acknowledges that the special needs of the detainee population, including any pre-existing illnesses, may require a higher level of services.⁽¹¹⁾

The IDS and Handbook provide for:

• appropriate accommodation and cleanliness of amenities
• 'food of sufficient nutritional value, adequate for health and wellbeing and which is culturally appropriate' as well as special dietary food where needed
• the care needs of each new detainee to be identified by qualified medical personnel as soon as possible
• the use of accredited interpreters with detainees being used as interpreters only in 'very exceptional circumstances'
• detainees needing specialist treatment to be referred or transferred to hospitals
• regular monitoring of care and medication needs
• provision of dental care necessary for the preservation of dental health
• immunisation and disease control.⁽¹²⁾

There is no specific provision for the special paediatric needs of children in the Handbook or the IDS, except that the IDS provide generally that the special needs of babies and young children are met and that unaccompanied children be detained in conditions which take account of their needs.⁽¹³⁾ However, the Handbook and the IDS both provide for the special health care needs of pregnant women, including the provision of an appropriate diet and baby equipment.⁽¹⁴⁾

(a) Department monitoring of the health care provided to children

The Handbook states that the Department Manager's role regarding health is:

to be aware of the standards of health care required, ... to monitor the Services Provider's activities and to ensure those standards are being met.⁽¹⁵⁾

In relation to unaccompanied children:

DIMIA Managers must ensure particularly that children are accessing and receiving appropriate health care. This includes having appropriate case management plans that specify any relevant health care needs for the child concerned.⁽¹⁶⁾

The Department contends that the monitoring of health care of detainees occurs through various general contract monitoring arrangements, including daily contact with centre managers, contract management meetings, incident reports and monthly update reports.

The weaknesses of the monitoring system generally, including the lack of expertise of Department officials in child welfare and the poor quality of incident reporting by ACM, are described in Chapter 5 on Mechanisms to Protect Human Rights. The quality of the case management care system for unaccompanied children is discussed in Chapter 14 on Unaccompanied Children.⁽¹⁷⁾

In addition to those systems described in Chapter 5, the Department also informed the Inquiry that an Expert Panel, which provides advice to the Department to support its contract monitoring and investigations, has expanded to include health professionals. The Inquiry has not received any information regarding the composition or operation of the Expert Panel.⁽¹⁸⁾

The South Australian Department of Human Services (DHS) has expressly addressed the nature of the IDS and the incident reporting system relating to health care, and suggested that those measures are insufficient to properly safeguard children:

The performance measures do not require essential primary health standards to be met but focus primarily on complaints or incidents. The absence of positive reporting based on standards for service delivery especially for those services that should apply to children and their families as basics ie hearing, eye, assessments of physical health status, psychological health and dental health and immunisation indicates the residual nature of the health and medical services that are provided compared with those available in the wider community. Many of the performance measures require substantiation but it is unclear what the process of substantiation entails.⁽¹⁹⁾

Despite some weaknesses in the Department's monitoring, it appears that the Department was aware of the need to improve the quality of health care provided in detention facilities. In 2001, the Department commissioned an independent review of ACM's provision of health services (the Bollen Report).⁽²⁰⁾ The Bollen Report, delivered to the Department in November 2001, noted substantial shortcomings in the provision of health care across the board and provided practical proposals for ensuring that the Department meets the standards of health care delivery. The Department has provided the Inquiry with updates, as at March 2002 and June 2002, of ACM's response to the Bollen Report's recommendations.⁽²¹⁾The findings and recommendations of the Bollen Report are referred to throughout this chapter.

(b) Payment arrangements between ACM and the Department regarding external health care

Detainees do not have access to Medicare provisions, requiring ACM or the Department to make full payment for any health services including dental, optometric, hospitalisation and pharmaceuticals. The remote location of the detention facilities exacerbates the financial burden of the provision of health care in detention. The longer children and their parents are detained the higher the need to address serious health problems.

The Department Handbook, dated April 2002, states that:

the Services Provider is responsible for costs of health care within [detention facilities], at day care facilities, at hospital outpatients and for referral to specialists. DIMIA is responsible for costs when detainees are admitted to hospital.⁽²²⁾

Yet in answer to the Inquiry's Notice to Produce evidence regarding the arrangements in place for the payment of external health care, the Department stated that:

In general, where health agencies or health service providers are engaged for the purposes of providing access to external medical specialists, hospital care or other external medical services required by children and their parents, they are engaged by Australasian Correction[al] Management (ACM) on a case by case basis.⁽²³⁾

The lack of clarity may be explained by the fact that, over the period covered by the Inquiry, there was no generic arrangement on health care costs across the detention facilities.⁽²⁴⁾

Rather, at Woomera and Curtin facilities, the Department met all costs of external hospitalisation including ambulances and care in hospital. The Bollen Report states that at the Curtin facility the Department also had financial responsibility for external health referrals, other than for dental and optometry care.⁽²⁵⁾

However, at Baxter, Port Hedland, Maribyrnong, Villawood and Perth 'ACM is generally responsible for hospitalisation costs but can charge the department for hospitalisation costs above two hospital days per 1000 detainee days'.⁽²⁶⁾ It also appears that exceptional expenses such as the Royal Flying Doctor Service evacuations and major surgery were covered by the Department, for Port Hedland at least.⁽²⁷⁾

The Department stated that:

all matters of medical judgement are the sole province of the responsible Medical Officer in accordance with the Services Provider's own procedural guidelines. No restrictions will be placed on any medical officer with respect to the practice of medicine.⁽²⁸⁾

Recommendations for non-essential external health treatment are assessed on a case-by-case basis.

The possible impact of cost considerations on doctors seeking to refer detainees for external treatment is discussed in section 10.4.6.

10.2.2 ACM policy on health for children in detention

The Department relied primarily on ACM to provide health services to children in immigration detention, in accordance with the IDS. ACM was responsible for employing health staff within detention and arranging access to services which could not be provided internally. However, the ongoing detention of children, the location of detention centres in remote areas, and the subsequent health implications, were not within ACM's control.

Although the Department's submission states that the health needs of child detainees were expressly referred to in many of the ACM Policies,⁽²⁹⁾ the only two examples identified by the Inquiry were the ACM Policy on immunisations⁽³⁰⁾ and the policy on provision of food, which required that infants and children be provided with diets appropriate to their needs.⁽³¹⁾

However, ACM developed operational policies regarding the health care for female detainees,⁽³²⁾ pregnancy,⁽³³⁾ general hygiene⁽³⁴⁾ and food services hygiene.⁽³⁵⁾ There was also a specific procedure on the provision of health care to those in the Woomera Housing Project.⁽³⁶⁾

In November 2001, Woomera IRPC implemented a general procedure that sets out the importance of implementing, monitoring and reviewing the ACM Health Services Policies and Procedure Manual.⁽³⁷⁾ The creation of a comprehensive health plan appears to have been a response to one of the many recommendations of the Bollen Report. In June 2002, the ACM Senior Health Services Manager advised the Department of progress ACM had made in response to the Bollen Report, including that:

Each Centre's Health Services Coordinator (HSC)/Sole Practitioner (SP) was required to meet with their health staff and Centre management team and determine what they considered to be the priority areas for quality improvement in health service delivery and what strategies were required to achieve the improvements.⁽³⁸⁾

10.2.3 State involvement in health care for children in detention

The Department and ACM inevitably needed to draw on the State health system for hospitalisation and external medical care. Detainees do not have access to Medicare so all services must be paid for by ACM or the Department. This required some cooperation at the operational level between ACM and the State health services.

It is somewhat surprising that there were no established or formalised procedures in existence regarding the access to and payment for external health services more generally.

For example, in December 2001, in the wake of the hunger strikes in Port Hedland and Curtin, arrangements were made between Fremantle Hospital in Perth and the Department whereby the hospital 'would accept transfers of those rare cases where the detainees' clinical status deteriorated to an extent that they require acute treatment in a metropolitan facility'.⁽³⁹⁾ The Department agreed to meet the costs of hospitalisation in this case.

The Department's submission indicates that it is in the process of negotiating more general agreements:

Where detainees need to access services provided by a State or Territory health service provider, [ACM] makes appropriate arrangements directly with that provider. The Department facilitates access to these services, by negotiating agreements with state government agencies, where necessary.

For example, at the request of the South Australian Department of Human Services (DHS), the Department has begun negotiations to develop a Memorandum of Understanding to formalise a framework for the provision of health services by DHS to immigration detainees in South Australia.⁽⁴⁰⁾

In August 2003, ACM informed the Inquiry that an MOU is in place with DHS for Baxter. However, there are no other agreements in place.

The Department states, and ACM agrees, that '[g]enerally, the absence of a formal agreement has not adversely impacted on access to State facilities or payment for such access'.⁽⁴¹⁾ However, the Inquiry is concerned that a lack of clarity over the process for referral and responsibility for payment has the potential to impact on the efficient provision of medical services.

10.3 Did children enjoy a healthy environment in detention?

I am primarily a paediatric doctor. I saw many of the children in [Woomera] as well as the other adults, of course my major concern is for the children and as they are the vulnerable ones, and really so many of their problems relate directly to the prolonged and indeterminate nature of their detention, which is a combination of the very harsh and isolated physical environment, the poor accommodation facilities and the lack of resources for primarily their mental health and the lack of resources for their leisure activities.⁽⁴²⁾

The detention of children places the responsibility for provision of basic items such as food, shelter, clothing and hygiene into the hands of the Department. It requires the Department to ensure that the physical environment is such that children can live a healthy life. It appears that this was the initial focus of the Department:

The Department's initial focus in the circumstances [of an influx in arrivals] was to ensure that all unauthorised arrivals were provided with the necessities. Good quality food in adequate supply, comprehensive medical services, safe clean accommodation, adequate ablution facilities, clothing and footwear appropriate to the circumstances. The demand for a rapid response required the Department to focus on the practical aspects of managing detention.⁽⁴³⁾

One of the questions considered by the Bollen review was whether there was a clear understanding amongst Department and ACM staff regarding the level of health care to be provided in the centres. The Bollen Report stated the following at the end of 2001:

The review identified differences in priorities amongst both ACM and DIMIA staff. Operational staff seemed to view health services as a necessary fulfilment of a contract rather than addressing a basic need. ACM management in most of the centres appeared to place most emphasis on security; DIMIA placed most emphasis on processing. Health care should be more than the provision of health services and must take into account issues of primary prevention including appropriate diet and extent of activity necessary to maintain health including mental health, and prevent illness including symptoms resulting from cultural as well as language misunderstanding.⁽⁴⁴⁾

The following sections assess whether the Department and ACM have properly accounted for diet and other environmental factors that can promote good health for children in detention.

10.3.1 Food

It is well understood that the healthy development of a child relies heavily on a healthy diet.⁽⁴⁵⁾ The Department and ACM acknowledge that food is a particularly important issue in detention centres:

In an institutional setting, particularly one in which people have only limited control over their lives, normal routines, such as meal times become a major part of daily activities. Understandably, food can become a particular focus. It is important, therefore, that the food is not only of good quality and nutritional but also interesting and appealing. ⁽⁴⁶⁾

Kitchen at Woomera, June 2002.

(a) Nutritional value and quality of food

The Inquiry received evidence that asylum-seeking children may suffer from preexisting nutritional deficiencies which can affect the long-term health of children, and must be addressed as soon as possible.⁽⁴⁷⁾ There is a high possibility that children arrive with parasites and other stomach ailments that will affect their health and lead to nutritional deficiencies. The Department and ACM have a responsibility to identify and address pre-existing nutritional deficiencies in order to satisfy the right to health under the CRC.

In response to recommendations in the Bollen Report, ACM engaged a consultant nutritionist in mid-2002 to evaluate the food at Woomera with the specific objective of determining whether there was a connection between the types of food served at Woomera and the high incidence of complaints relating to gastric disorders.⁽⁴⁸⁾

The nutritionist recommended that there be:

Initial nutritional health assessment for all detainees with special reference to:

1. Growth
2. Nutritional deficiencies
3. Problems associated with food intake and behaviour.⁽⁴⁹⁾

In its response to the draft of this report in August 2003, ACM states that it put in place strategies to address the nutritionist's recommendations. These included assessments of children's growth against growth charts at intervals appropriate to a child's age, which is used as an indicator of nutritional deficiency. ACM also states that any dips on the percentile growth rate result in referral to a paediatrician. The children's food intake and behaviour is also monitored by a nurse. However, it is unclear whether these measures were put into place at all centres, as a procedure from initial arrival. The Inquiry did not receive evidence that detailed individual assessments were conducted on children during the period of time covered by the Inquiry, which included growth charts and detailed information on nutritional deficiencies.

On the other hand, ACM also states that in June 2003 a team of six health workers from the SA Child and Youth Health Services attended Baxter to undertake individual assessments of the health status of children, including nutritional status.⁽⁵⁰⁾Assessment details were kept in the children's individual 'blue books' as occurs in the outside community for babies. The Inquiry commends this initiative. However, it notes that these procedures do not appear to have been in place at all centres during the period of time covered by this Inquiry.

In terms of the food supplied by ACM, the ACM consultant nutritionist noted that as at May 2002, the basic nutritional components (ignoring any special nutritional needs) were available in meals served at Woomera.⁽⁵¹⁾

A paediatric registrar working at Woomera also commented to the Inquiry that:

I didn't see any cases of malnutrition at the centre. I did see cases of weight loss, which I think reflected the depression that these children were under, very poor weight gain. I think the diet is probably just about adequate in the short term.⁽⁵²⁾

However, the ACM nutritionist also pointed out that the nutritional components of meals are not necessarily related to 'actual total food consumption' of detainees and the needs of individuals vary widely.⁽⁵³⁾ Hence the amount of food consumed may be linked to the quality of the food served.

One former ACM staff member suggested that the issue of food quality could have been linked to an inadequate budget allocation. He was of the view that when he was Operational Manager at Woomera and Centre Manager at Perth the allocated amount for food expenditure was never enough.⁽⁵⁴⁾For example, he recalled that the budget for food in Perth detention centre when he was there was roughly four dollars per person per day, and had remained stable despite an increase in costs.⁽⁵⁵⁾ ACM disputes that cost-cutting resulted in low quality food.⁽⁵⁶⁾ Further, when the question of food budgets was put to ACM during the December hearings, ACM responded:

There is no average allocation for food or per diem as such in the operating budgets of the detention centres. The idea of an average allocation is an artificial concept used as a step in setting the indicative budget for food procurement each year. Broadly speaking, the food budget for each centre is derived by taking the dollar amount for each detainee expected to arrive at the centre and adapting that figure to suit anticipated future expenditure based on historical patterns of expenditure on food.⁽⁵⁷⁾

It does, however, appear that rough allocations were given for food expenditure, which differed in each centre. One of the ACM monthly reports provided to the Inquiry states that the cost of meals per detainee per day at Curtin in December 2001 was $6.35.⁽⁵⁸⁾ The Inquiry also received evidence that detainees in the Woomera Housing Project were given seven dollars per person per day for food shopping, although that may be varied where 'smaller family units cannot avail themselves of the advantages of bulk buying'.⁽⁵⁹⁾ The Inquiry did not receive any other evidence linking allocated budget and food quality.

Nonetheless, it appears to the Inquiry that the quality of food varied over time and between centres. In Port Hedland during the January quarter of 2001, the Department Manager comments that the '[q]uality and range of food, and standards of cooking, is very good'.⁽⁶⁰⁾ However, from November 2001 to May 2002, the Department Manager at Curtin noted continuing complaints about the quality of the food provided to detainees.⁽⁶¹⁾

The issue of food quality at Curtin was raised in the June 2002 Contract Operations Group Meeting, with the Department noting serious dissatisfaction with poor food handling practices, including the preparation of meals several hours before they are eaten. 'Hot boxes' or 'insulated food storage systems' were used to keep the food warm,⁽⁶²⁾ a practice which encourages the growth of dangerous bacteria. ACM states that the hot boxes can safely store food for in excess of five hours.⁽⁶³⁾ However, in April 2001, the ACM Services and Assets Manager noted that the practice at Curtin of thawing frozen goods at warm temperatures raised the possibility of food borne infections, and that additional equipment was required to deal with this problem.⁽⁶⁴⁾ To the Inquiry's knowledge, this equipment was never purchased due to the imminent closure of Curtin.

During the Inquiry's visit to Baxter in mid-December 2002, the use of hot boxes was still current.⁽⁶⁵⁾ This was seen as part of a more flexible policy towards availability of food outside standard mealtimes.

In September 2001, at Woomera it was alleged that, 'food was twice found to be contaminated by fly larva'.⁽⁶⁶⁾ This observation accords with many comments from children who said they saw maggots in the meat.⁽⁶⁷⁾

After we saw many times insects in the food, we changed all the cooks and we got the Iraqi and Afghani guys to cook for us.⁽⁶⁸⁾

In response to this incident, ACM and the South Australian Department of Environmental Health investigated the quality of the kitchen hygiene and eventually started a spraying program to remove flies, installed air curtains at the mess doors, fly screens at the windows and air conditioning in the dining rooms.⁽⁶⁹⁾

Visitors to Woomera also commented on the quality of the meat.

We had actually seen some of the food. It was meant to be meat. It was quite indescribable when we saw it.⁽⁷⁰⁾

Some children also alleged that the food was old:

Sometimes when they bring the food in here and we are really hungry, there is stinky food in here that they offering to the people inside the compound and most of the time, we said, please change this food, this food is not eatable and very bad, and most times the food is rotten, the bread is mouldy as all the detainees said.⁽⁷¹⁾

The Department provided the Inquiry with examples of weekly menus from Baxter, Perth and Villawood centres in its response to the draft report, which reveal efforts to provide variety at lunches and dinner, although not breakfast, at these centres.⁽⁷²⁾However, the Inquiry heard a number of people raise the issue of the monotony of diet at Curtin in particular for some of the period covered by the Inquiry.

The Curtin Department Manager raised the issue of the monotony of the menu in the early months of 2002:

A number of detainees requiring special needs, including vegetarians, and those on high protein diets received for a period of approximately five weeks ... the same meals for lunch and dinner. This consisted of steamed vegetables and steamed chicken.⁽⁷³⁾

Similar comments were made by detainees:

The parents said the diet was monotonous, with the same type of food served up day after day. It consisted of rice, some sort of meat, lettuce, tomato and bread. Most days they could not tell what meat was being served up and they avoided eating it as they do not eat red meat, so they had no regular source of protein. They lost interest in their food and lost weight. In other circumstances, a meal might be something to look forward to, but they just went through the motions of eating before returning to their compartment.⁽⁷⁴⁾

Many children also commented on the lack of variety of the food:

Always vegetables. Sometime chicken.

There was the same food always. Every day. They didn't change it.

There were lots of vegetables and chicken and rice.

Apples, every day.⁽⁷⁵⁾

The food was nutritious maybe, but just nutritious. You had cornflakes and milk every morning and chicken and rice at lunch and dinner.⁽⁷⁶⁾

The Curtin Manager reported that despite repeated requests by the cooks to ACM management, they were not provided with ingredients or cooking tools to provide a varied menu. Eventually the staff gave up asking.⁽⁷⁷⁾

Inquiry staff ate the food provided to detainees during its visits to detention facilities and found it to be of acceptable quality. However, some detainees commented that the food improved immediately prior to the Inquiry visits.

Furthermore, it must be remembered that whereas a basic menu can be tolerated for a short period of time, after many months in detention the monotony of diet can add significantly to feelings of frustration and powerlessness. Hence, in detainee representative meetings, food and menus feature frequently in discussions with management.⁽⁷⁸⁾

A further possible reason for some of the detainees' comments may be that the type of food being served was not always culturally appropriate. This is discussed in Chapter 15 on Religion, Culture and Language.

(b) Special meal arrangements for children

The ACM Policy with respect to food states that 'infants and children shall be provided with diets appropriate to their needs'.⁽⁷⁹⁾ Moreover, ACM has stated that:

As a general principle, the nutritional needs of children are always taken into account by ACM when planning the menus for each centre. All menus are checked and approved annually by qualified dieticians.⁽⁸⁰⁾

ACM also provided a list of the dietary arrangements made for children between 1999 and 2002. As discussed above, it appears that ACM made some efforts to provide nutritional meals three times a day. However, the Inquiry is concerned that the institutional environment of detention hinders the capacity to adopt a flexible approach to meal arrangements, which is needed especially for small children.

In response to the draft of this report, the Department states that 'in institutional settings, such as a hospital or boarding school, it is generally necessary to place some structure around mealtimes'.⁽⁸¹⁾ The Inquiry understands that for the sake of efficiency within a detention environment it is necessary for ACM to organise set mealtimes. However, it is unusual for small children to be in an institutional setting for long periods of time. Every effort must be made to make life as normal as possible and to assist parents to address their children's dietary needs as they see appropriate.

ACM states that there are issues associated with the safe storage of perishables in Australian's warm climate and that there are logistical issues with the capacity of suppliers to make regular and reliable provision of large quantities of fresh supplies in remote areas.⁽⁸²⁾ These comments indicate that the remote location of the centres may also have added to the difficulties of providing special food for children.

As discussed by a child health specialist, grazing is normal behaviour for children:

One of the things we recognise in the mainstream community is that the children need to be offered a variety of tasty and nutritional foods, particularly for younger children who don't have the kind of adult appetite that we do. They are often best served by allowing to graze on food during the day, have healthy snacks in between meals so that their nutritional requirements are met and that is just a fact of good childcare and what we know about children's eating patterns, that they don't necessarily eat at set meal times, three meals a day, as might be offered in an institutional setting. They eat when they feel hungry and that depends a lot on the individual child and their level of activity.⁽⁸³⁾

ACM states that it is 'ACM practice to give access to food outside of the regular three meal times to children and adolescents', and that 'toddler food, extra fruit and formula are routinely distributed on a daily basis to parents'.⁽⁸⁴⁾ Focus groups with children suggest that some facilities did provide milk, fruit and bread to young children between meal times. However, this does not appear to have been uniformly applied during the period of time covered by the Inquiry. For example, children in focus groups reported that:

In Port Hedland there was no difference in the food for adults and for children. They were using sometimes certain types of spices and things that even the adults could not eat, so the kids would not eat it. They would give them only one glass of milk, in the mess and if they did not drink it, that's it, they wouldn't give anything to take to the rooms.⁽⁸⁵⁾

If you went for the food and you were late, you couldn't have any food. If you woke up late in the morning there was no breakfast ...There were no snacks between the meals. ⁽⁸⁶⁾

At Woomera, at least until early 2002, when parents wanted food for their young children that was different to that served to everyone else, they required a medical certificate. A paediatrician working at Woomera for two weeks in 2001 and again for two weeks in January 2002 stated that:

... I spent a great deal of time and I think [the other doctor] did as well, where we would simply write letters of recommendation for a child, especially the infants and anyone under the age of five, to have dietary supplementation in the form of fruit, yoghurt, snacks. I never experienced any success with any of these letters at all, in my experience.⁽⁸⁷⁾

A nurse at Woomera in 2000 recounted a similar difficulty:

...there was one woman, for instance. She was asking if the child could perhaps have some soup to eat rather than - the child was five years old, could the child perhaps have some soup because the child does not like the food that is being provided there. Now, with requests like these, the parents would be sent to the medical centre. We were instructed not to allow the child to have such - the soup, unless there was a particular medical reason that would have prevented the child from eating other food.⁽⁸⁸⁾

A nurse who worked at Woomera on three six-week contracts between August 2000 and February 2001 stated that:

Medical centre staff regularly heard complaints from detainees about the quality of the food that was provided at WIRPC. The food that was provided in my opinion was neither nutritionally adequate nor culturally appropriate. Detainees' requests for simple food items such as rice, yoghurt and lemons were ignored.

Detainees were only allowed 250ml of milk and one piece of fruit per day. This was not adequate for pregnant women, lactating mothers and children.

To overcome this, nurses would take milk to the medical centre and provide [it] to women and children.

Medical centre staff regularly wrote letters requesting special meals for detainees, particularly women and children. The ACM centre manager, through the health manager directed us to stop writing letters requesting special meals.⁽⁸⁹⁾

Another nurse at Woomera told the Inquiry about the father of a sick child who asked for extra bananas as it was all his son was interested in eating:

I recall that an officer and the kitchen manager, on several occasions said to me, and not infrequently in the presence of [the boy and his father] 'There are no bananas', 'They are in short supply', 'We won't be getting them in'. These comments were made even when bananas were in stock ...Upon my taking this up further ...the kitchen staff member said to me 'No bananas - they're too expensive to give out'.⁽⁹⁰⁾

During the Inquiry's visit to Villawood in August 2002, one detainee alleged that she had to continually ask the cook for extra milk even though she had authority from the doctor for this item. However, evidence from children in the remote centres suggests that milk was usually available after hours.

Some parents stated that they went without some items in order to create another meal for their children, or to give the child the only food they wanted.⁽⁹¹⁾

Some of the problems discussed above appear to have been gradually addressed by the provision of fridges to store meals.

(c) Baby formula and food for infants

Both ACM and the Department stated that baby formula was always available from the medical centres.⁽⁹²⁾

While the situation may have improved in 2002, the Inquiry heard a number of complaints about the provision of baby formula at Woomera during 2000 and 2001 which seem to confirm that procedures have been less than perfect. For example:

When I first visited Woomera there were repeated complaints from people with young children that they couldn't get formula for their children. Letters were written asking for better care but they were constantly complaining that they couldn't get proper food for babies.⁽⁹³⁾

A former ACM Operations Manager who was at Woomera for a period of 16 months from early 2000 until July 2001 reported:

I've seen mothers ask for milk for their babies and it's been poured out of a plastic two litre container, [for] new babies. They wouldn't have done it if [it was] their own wife ... [no formula milk was offered] when I was there, not that I saw anyway ... and I know that the medical staff were trying very hard to do something about it ... it's something that had never been thought of. I must say on that, and on the whole thing I guess, that, in my view, ACM went into this thing totally unprepared and probably not willing to really learn.⁽⁹⁴⁾

One doctor who had worked at Woomera stated that she did not experience a problem in obtaining supplies of formula. However, she was of the view that 'there was no set procedure to make the order and it was done in a very ad hoc manner'.⁽⁹⁵⁾

ACM also alleges that some detainees complained that the brand of formula was wrong because it was not what they were accustomed to, and then would refuse the product on this basis.⁽⁹⁶⁾ On the other hand, the Inquiry was told by one ex-detainee that 'sometimes they would make mistakes and get the wrong formula for our babies, which is for older babies, for older children'.⁽⁹⁷⁾

Other evidence suggests that while baby formula may have been purchased by ACM, a poor distribution system meant that it was difficult for mothers to access baby formula when they needed it.

In relation to a family with two infants, DHS found:

The family is required to pick up formula day and night from the medical centre (detainees are not permitted to have glass bottles). The family doesn't have access to food and feel they cannot meet the babies immediate hunger needs. There is no fresh food available, the food is pre-packed.⁽⁹⁸⁾

One detainee mother claims she requested a tin of formula for her room, as it was inconvenient to have to ask for formula for the baby in the middle of the night, for example, but she was refused.⁽⁹⁹⁾ She also claimed that she had difficulty convincing medical staff that she could not produce breast milk and was therefore denied formula:

I kept going back to them requesting some formula for my son but they would say, 'No, you have to breastfeed him'. I would continue saying, 'I don't have any milk' but they would insist on not giving me anything until, for one week, I was giving my child water and sugar for one week ...⁽¹⁰⁰⁾

It is possible that this situation may have resulted from misunderstanding about lactation practices. ACM claims that it is common practice to support lactation by offering the baby drinks of water, rather than formula, which stops the baby dehydrating and encourages the baby to keep sucking. However, even if this is so, the mother's comments only highlight the problems and misunderstandings which can occur when mothers are forced to rely on detention staff for the daily provision of formula, rather than being free to nurture a baby according to their own wishes.

A nurse who worked at Woomera on three six-week contracts between August 2000 and February 2001 also expressed concerns about the manner in which baby formula was prepared at the time:

During my period of employment at WIRPC there was only one sink with only cold water in the Medical Centre. This led to unhygienic practice, for example the making up of formula milk for babies in the same sink where faeces were decanted into pots prior to being sent to pathology.

During my first two contracts at Woomera there were no sterilisation facilities in the Medical Centre. During my last contract there was a sterilisation machine, however, there was no instruction booklet, no indicators that sterilisation had been completed and no records kept of sterilisation procedures.⁽¹⁰¹⁾

The Department informs the Inquiry that clear procedures on formula preparation have been in place for 'quite some time'.⁽¹⁰²⁾ It stated that:

health staff sterilise all the equipment required for the provision of infant formula. The formula is prepared in individual bottles according to the feeding requirements of the infant or infants at the IDF health centre. All the bottles are clearly labelled to avoid mis-identification. They are refrigerated at the health centre or in a similar convenient location in the centre and that parents or detention officers are able to collect the bottles from the health centre staff as required.⁽¹⁰³⁾

However, it is unclear when such procedures were introduced at all centres.

(d) Findings regarding food

The Inquiry recognises that there have been recent improvements with the decreasing numbers in detention and increasing participation of detainees in food preparation. However, the Inquiry finds that there was insufficient systemic attention paid to the special dietary needs of children throughout 1999-2002. The variable quality of the food made it unappetising, and sometimes unhealthy, for children and their parents, as did the monotony of the menu, especially over long periods of time in detention. The regimented meal times were unsuited to the needs of small children and for a substantial period of time the provision of baby formula at Woomera was uneven. Moreover, although it is commendable that ACM engaged a nutritionist to generally assess food at Woomera, there is no evidence that individual nutritional assessments of children were conducted over the period of time covered by the Inquiry, in order to ensure that any pre-existing nutritional deficiencies were being addressed on a case-by-case basis.

10.3.2 Physical surroundings and climate

The most obvious physical hazard to children in detention facilities arises from the violence to which children are exposed. This issue is discussed in Chapter 8 on Safety. However, the Inquiry also heard that the desert location of Curtin and Woomera in particular meant that children were exposed to a harsher physical environment than in city centres. Although the Inquiry notes that there have been gradual attempts to counter some of the harsh aspects of the surroundings and climate, for example by installing air conditioning, the location of these facilities is not ideally suited to maximising children's health.

One physical hazard frequently raised by children was that the absence of grass and the rocky surface meant that they often hurt themselves when they were playing soccer. An unaccompanied boy, detained at Woomera IRPC until early 2002, told the Inquiry that 'when we played we badly hurt ourselves because of the rocks. It was very difficult for us'.⁽¹⁰⁴⁾ This problem was exacerbated by the absence of closed sports shoes.⁽¹⁰⁵⁾

There is no shoes for sports, so I love to play sport and when you were playing bare feet you were getting injured and there was no medication.⁽¹⁰⁶⁾

Gradually some astro-turf was laid and soft-fall matting arranged under play equipment but the playing fields were still dirt.⁽¹⁰⁷⁾

The Inquiry heard complaints from detainees about eye and skin infections caused by the glare, dirt, and dust storms.⁽¹⁰⁸⁾ An organisation in Western Australia noted that it was referring many former Woomera detainees to optometrists 'because of damage to their eyes, due to lack of shade in the detention centres'.⁽¹⁰⁹⁾

Woomera compound (clotheslines in background), June 2002.

The extreme heat and cold of the desert climate also caused problems. A doctor working at Woomera stated that:

...a lot of the other problems were due to the location of [Woomera] which, as you know, is in the middle of a very isolated area in the middle of South Australia. When I was there it was during a very cold time and at nights the temperature often went below zero. And I would see many children brought in by their mothers with respiratory infections and then, at the same time as trying to treat them, the mothers would be asking me if I could write letters to the centre organisation to get heaters put into their rooms because they did not have any.⁽¹¹⁰⁾

National Legal Aid recounted a case study which suggested that there was inadequate heating in the accommodation.

The five family members were allocated a small cubicle about the size of a railway compartment, with bunk beds. Instead of a door there was a curtain that did not reach the ground and would cover an adult of average height from about the neck to the knees. There was therefore very little privacy or soundproofing. There were six such compartments in a small, enclosed area. Being winter, it was very cold. The building was poorly insulated and there was only one small heater between the six families. There were constant fights over who would have the heater near their compartment. To keep warm, families huddled together on their beds wrapped in blankets.⁽¹¹¹⁾

On the other hand, the hot temperatures were also a problem. Reverse cycle air conditioners had been installed in a number of areas in the remote centres. However, as children are frequently outdoors, the heat continues to cause some problems. Children who had been detained in Curtin described the discomfort caused while queuing up to see a doctor:

If they were sick, they didn't take it seriously at all. They had to queue in the hot sun outside the clinic. On hot days some of the people who were sick got worse from standing in the hot sun.⁽¹¹²⁾

The heat also caused discomfort around meal times. One child described the process of queuing for food as follows:

I would like to say about the queues. Lunch was the most hard to bear, as it was 45, sometimes 55 degrees, and you were standing out there in the sun, with 1200 people trying to get in and be fed in a small kitchen. There was a queue inside, and a queue outside, and people, sometimes they had to stand up to eat. Sometimes we even ended up fighting with each other because somebody would break the queue and the guards wouldn't do anything about it.⁽¹¹³⁾

Medical staff interviewed during the Inquiry's visits reported that dehydration was a common problem and they spent much of their time encouraging children to drink more water.

Current and former detainees also spoke of the prevalence of insects:

In winter there was a lot of mosquitoes. Especially after 5pm, you can't stay out of your donga [demountable sleeping quarters]. We had lotions to repel the mosquitoes. The guards had sprays, which was much easier.⁽¹¹⁴⁾

Several children also mentioned the presence of poisonous snakes and scorpions.⁽¹¹⁵⁾

Once I had a very high fever at night and the doctor came to treat me. I had a scorpion bite.⁽¹¹⁶⁾

A specimen of a venomous brown snake caught by detainees in Woomera was shown to Inquiry staff.

The Department's practice of isolating new arrivals until they make an asylum claim in 'separation detention' poses additional hurdles.⁽¹¹⁷⁾ Detainees in Port Hedland in particular referred to the absence of fresh air during the period of separation detention:

My husband and the little one, they were in a small room ...They used to open up just the door for them only for 5 minutes ...just to have fresh air and go back again, and they were very distressed both of them.⁽¹¹⁸⁾

For seven months we were held in a closed detention centre where we used to be taken out for half an hour for fresh air and viewing ....⁽¹¹⁹⁾

A case study provided in the submission from the Alliance of Health Professionals stated that:

Upon arrival in Australia in early 2000, the family was placed in a detention centre in a very small cell. The parents were allowed out for ten to fifteen minutes in the morning and in the afternoon.⁽¹²⁰⁾

The impact of separation detention on children's right to recreation is discussed further in Chapter 13 on Recreation.

(a) Findings regarding physical surroundings and environment

The location of, and physical conditions in, some centres bring inherent hazards to health. The extreme temperatures in the desert caused children great discomfort and the dust and glare appears to have caused several children eye irritations. On the other hand, children in separation detention appear to have had very limited access to the outside environment.

There were periods during which there was insufficient indoor heating and cooling. While similar issues exist for children in the community they, unlike detainee children, have some choice as to where to go for shelter from the heat and cold. Moreover, they are unlikely to be in the position of having to line up outside in order to eat their meals and see the doctor. The Inquiry notes that Curtin and Woomera, two centres with harsh physical environments, were decommissioned in September 2002 and April 2003 respectively.

10.3.3 Clothing

The IDS require that, where detainees do not have adequate clothing and footwear, they are to be provided with such items suitable for the climate.⁽¹²¹⁾ The Department informed the Inquiry that clothing and footwear was distributed on a needs basis through the purchase by ACM of second-hand clothing from charities and certain items of new clothing such as underwear and footwear. Detainees could also purchase clothing and, in some centres, detainees could choose to make extra clothing in sewing workshops. The Inquiry also received evidence that substantial clothing donations by community groups occur in some centres.⁽¹²²⁾

Notwithstanding this variety of sources, the Inquiry received evidence that, at least during certain periods, the clothing given to children in detention was inadequate for their needs. The Coalition Assisting Refugees After Detention (CARAD), a community group in Western Australia which assisted families upon their release, reported the following:

[M]any people report that they have their own clothes taken away from them when they arrive in Australia and they are often only given the most minimal set of clothing and, you know, mothers turning to making bed sheets into clothing for children because they do not have enough clothes for the children to wear. Children on release arriving in Perth without shoes, for example; a family of 4 with one shopping bag of clothing for all 4 of them. One of the first things we have to do with CARAD is to provide all of the family with clothing because they simply do not have enough clothing and they have been in the habit of taking off one shirt, washing it overnight and putting it back on the next day because that is all they have to wear.⁽¹²³⁾

Other community groups that visited children in various detention facilities stated that they often brought clothing for the children. Children also reported that:

[ACM] were not providing enough clothes in the camp. They would sell clothes, but there were a lot of people who didn't have money, so we would see lots of people with bare foot and they would have their feet wounded and hurt because they are barefooted.⁽¹²⁴⁾

The Department Manager at Port Hedland first noted a shortage of clothing for women and children in October 2001.⁽¹²⁵⁾ In January 2002 the Manager reported that:

The ACM approach to supplying adequate footwear under the detention standards is barely adequate, in that most residents complain they are provided with rubber thongs and insufficient clothing.⁽¹²⁶⁾

The Manager reiterated her comments in February 2002 but added that detainees were not given the opportunity to buy their own clothing to supplement that supplied by ACM:

There are continuous complaints from residents that clothing and footwear from ACM Welfare is inadequate and that they are not permitted sufficient shopping excursions to buy these items.⁽¹²⁷⁾

A nurse working at Woomera in 2000 recounted the complicated process of obtaining appropriate shoes:

... there was one time when a woman was asking me for some shoes, and the big charity truck had arrived. And everybody was in such a big hurry that the sandals that she got for her nine year old, or ten year old daughter did not fit. So then she came to the medical department because she had blisters on her feet. And then I said, well, you know - and then she said - I said, 'Okay, let's see if we can get you some more sandals'. And so we put in a second request. The second time around the mother was somewhere else. A guard came. Took the child. She picked her own size. And these sandals did not fit again. Second time around, the woman could not then get another pair of shoes or sandals because she was told she has already had two pairs.⁽¹²⁸⁾

The Department states that in 2001 the ACM practice was to provide detainees without appropriate footwear, with thongs in the summer and closed shoes in the winter.⁽¹²⁹⁾ Although it is possible, as the Department claims, that some detainees did not accept closed shoes, the Inquiry heard from a number of detainees that they were not offered these shoes when needed.

During its June 2002 visit to Woomera, Inquiry staff noted that despite the extremely cold temperatures several children were wearing thongs.

(a) Findings regarding clothing

Although it appears that detainee families were able to access adequate clothing provisions generally, the provision of appropriate shoes was a problem for children in the remote centres. Considering the extreme climatic conditions of the desert centres, and the harsh ground cover, adequate shoes are essential for preventative health care. As detainees are not free to buy their children shoes when they are needed, it was incumbent on the Department and ACM to ensure that children were provided with adequate footwear.

10.3.4 Crowding

Over 2002 the detainee populations decreased and the accommodation areas were relatively empty. However, some submissions noted concerns about overcrowded accommodation prior to that time, especially at remote centres.⁽¹³⁰⁾As noted in Chapter 3, Setting the Scene, several of the remote detention facilities have been populated beyond their capacity at times covered by this Inquiry.

In particular, starting at the latter part of 1999, there was a very significant increase in the number of unauthorised arrivals to Australia. The population peaked in August 2001, and this stretched centres to full capacity. Port Hedland exceeded its 800 person capacity in January 2000, when there were 839 detainees of whom 90 were children. Woomera's nominal capacity was 1200, but from March to July 2000, and again from September to October 2001, the population was above that number. Curtin's nominal capacity was 800 detainees, but between December 1999 and September 2000 it exceeded that capacity, and did so occasionally during 2001.⁽¹³¹⁾

Many of the families in the remote detention facilities had to share small demountable buildings (dongas). In Woomera they were separated only by a curtain. As the detention population decreased in the various centres, some families had a donga to themselves. A family at Curtin told the Inquiry that:

For one and a half years we were in a single room, living there. We were living in a single room, very small, I don't know, you came before us, you notice that. But now because it is less crowded in camp, the reduced number, we had a chance to get a room little bit larger.⁽¹³²⁾

In addition to causing mental stress, the shared accommodation raised cleanliness concerns. However, several submissions note that the lack of privacy was a primary concern of families.⁽¹³³⁾ Health staff at Woomera stated that the shared accommodation meant that parents needed to keep their babies quiet and this minimised the impact of any programs to encourage the development of babies.⁽¹³⁴⁾

The bunk beds also raised problems for families with young children. In April 2002, the DHS examined the circumstances of several families and found that, in relation to one family:

There is no safe sleeping environment for the baby, the family are sleeping on the floor on blankets because they have access only to bunk beds which is not safe for an infant or 2 year old.⁽¹³⁵⁾

The Inquiry also received evidence of an infant girl who fractured her ankle falling off a bunk bed shortly after arrival at Woomera.⁽¹³⁶⁾

Accommodation room at Curtin, June 2002.

(a) Findings regarding crowding

The Inquiry acknowledges that infrastructure limitations create difficulties in accommodating sudden increases in the detainee population. However, unpredictable influxes are to be expected in the context of immigration detention and appropriate contingency plans should be in place. The Inquiry is therefore concerned that the Department was unable to deal with these increases expeditiously. While the detention facilities are no longer as crowded as they were during the period 1999-2001, the conditions at the time caused great discomfort and stress to children and their families. One option may have been to transfer children and families to alternative places of detention.

10.3.5 Hygiene

The bulk of cleaning in remote centres was undertaken by detainees who were paid the equivalent of one dollar per hour. The Department's Infrastructure Manager at Woomera in 2000 stated that:

with the ablutions it didn't need a supervisor to do that other than necessarily a block officer who would expect the toilets to be cleaned twice, three, four times a day or whatever was necessary. It seemed that people volunteered for these types of duties to relieve their boredom, to give them some sort of commitment. Why there weren't regular cleaning teams going through, I don't know. Again, a cost factor and I would imagine that it was an agreement under their contract that it was something that could be done by inmates.⁽¹³⁷⁾

ACM states that the arrangements were 'designed to provide detainees with the opportunity to take a degree of responsibility and ownership over their living environment' and that 'for the most part, this was successful'.⁽¹³⁸⁾

However, during periods of tension and unrest in the facilities, some of these jobs were not done. For instance, during the Inquiry's visit to Woomera in June 2002 staff observed faeces on the floor of the toilets. The Inquiry was told that the toilets had not been cleaned in a few days because the detainees were on a hunger strike and were therefore not doing their assigned tasks. When asked why alternative arrangements had not been made to keep the place clean, neither ACM nor the Department could provide an answer.

Hygiene in toilets was also reported to be a problem in Curtin and Woomera in the June quarter of 2000.⁽¹³⁹⁾ Moreover in the March quarter of 2001 the Woomera Manager reported that:

Better maintenance of ablution blocks is required - is a continuing problem, which needs a structured maintenance and detainee educational program together with detainee assistance in quality control.⁽¹⁴⁰⁾

Some of the problems may have arisen because of the different style of toilets used in Australia than in the countries from which the detainees originate. Nevertheless, the submission from National Legal Aid states that:

The parents described the toilet facilities at the [first IDC] as putrid. For more than two hundred people, there were five toilets for the males and five for the females. The ground outside was muddy, and with people of many cultures using the western style toilets, the toilets were never clean. They said facilities for washing were too awful to describe.⁽¹⁴¹⁾

ACM gives the age of the infrastructure in some centres, which is the Department's responsibility, as a further explanation for the lack of cleanliness of the toilets. It states, for example, that bathroom facilities at Stage One at Villawood, are 'aged and cleaning does little to enhance the appearance and hygiene of the area'.⁽¹⁴²⁾

In November 2001, December 2001, January 2002 and February 2002 the Port Hedland Department Manager expressed concern about the cleanliness of the accommodation blocks. For instance in February 2002, the Manager notes that:

The general cleanliness and state of disrepair of the accommodation buildings, particularly of ablution blocks is unsatisfactory. Upper India, Juliet and Echo blocks remain unclean and unattended, despite low resident numbers providing an opportunity to clean them thoroughly.⁽¹⁴³⁾

This problem appears to have been rectified by ACM taking more direct responsibility for the cleaning and maintenance. By March 2002, the Port Hedland Manager notes 'significant improvements in the overall appearance and cleanliness of the accommodation blocks' as a result of the appointment of specific ACM Block Officers.⁽¹⁴⁴⁾

(a) Findings regarding hygiene

The Inquiry finds that there were insufficient systems in place to ensure an acceptable level of hygiene in bathrooms, which were used by adults and children alike. While it is not necessarily inappropriate to allocate cleaning jobs to detainees, this does not absolve the Department and ACM from the responsibility of ensuring that when that system fails, contractors are brought in.

10.4 What health care services were available to children in detention?

The following sections consider the policies and practices of Department and ACM staff regarding the prevention, identification and treatment of the health problems of children in detention.

Cot in the medical centre at Baxter, December 2002.

10.4.1 Health assessment and treatment procedures

One of the problems faced by the Inquiry in assessing the health levels of children in detention generally was the absence of systemic evidence. Although ACM did collect some data relating to health services, for example the numbers of persons hospitalised, the Department acknowledged that there was no consolidated statistical data of different categories of medical conditions.⁽¹⁴⁵⁾ The low level of data analysis was an issue addressed by the Bollen Report and appears to have been an ongoing issue for ACM.⁽¹⁴⁶⁾

One of the reasons for the lack of systemic data about the health of children in detention may lie in the perfunctory nature of the health assessment procedures. When children arrive in detention facilities, two types of health assessments are conducted which determine their care needs while in detention. First, there is public health screening which is concerned mainly with the identification of communicable diseases such as typhoid and tuberculosis. Second, there is screening for the purpose of identifying the general health needs of each detainee so that appropriate health care can be provided.⁽¹⁴⁷⁾ After the initial assessments there should be an ongoing process of assessing and diagnosing symptoms.⁽¹⁴⁸⁾

Children arriving from countries all over the world may have a variety of ailments that are not common to Australia, and therefore require specialised assessment procedures. However, evidence received by the Inquiry suggested that the initial assessments, based on a pro forma assessment form and conducted by nurses, may be insufficient to identify the pre-existing problems facing asylum seeker children. The Melbourne International Health Group stated:

Now it is our information that the initial assessment is conducted by a [Registered Nurse] and they are most looking for infectious diseases like TB. I have worked in refugee camps and with UNHCR and I have got about 20 years experience with refugees in and out of camps so in a refugee camp in Somalia, the first thing is an initial assessment which is comprehensive. In that assessment, you are going to pick up anything which may indicate nutritional problems. For example, a child may be in a refugee camp in Pakistan for a long time, been on the sea for a long time, and they may be having micronutrient deficiencies that are manifest as changes in the eyes so you check the eyes, the ears and every other thing. You will pick up nutritional deficiencies and develop a base line against which to measure any changes as you go along, so you need competent staff at that initial assessment for a start ...⁽¹⁴⁹⁾

The Bollen Report raised the concern that the procedure is difficult to follow when there are sudden intakes of detainees. It also raised issues concerning the lack of systematic follow up:

At the detention centre a nurse undertakes a health assessment on each detainee within 24 hours of admission. Nurses use a pro forma admission sheet to obtain a medical history and follow a protocol to record basic observations and urine analysis. In practice this timeline is impossible to achieve when a detention centre has large intakes of detainees over short periods ...

A medical officer does not routinely review the admission sheets. Detainees are referred to the medical officer if they have a medical condition volunteered to the nurse, or have some abnormality identified by the nurse considered sufficiently important or urgent. There is no formal protocol or specific criteria for such referral.⁽¹⁵⁰⁾

There is some evidence suggesting that the initial assessments were child-specific and varied depending on the age of children. The primary measurements taken were weight, height and dietary intake. There was also an assessment of immunisation status. However, only those in the age group 0-5 years seem to have had any testing relating to sight ('visual acuity' and 'squint test'), and there is no reference to hearing issues for any age group.⁽¹⁵¹⁾ The Department contends that sight and hearing testing is undertaken by Health Services Australia as part of the visa application process but this does not necessarily translate into service provision.⁽¹⁵²⁾ ACM also confirms that hearing, at least, was not provided in the first round of assessments.⁽¹⁵³⁾

Some children expressed concern about their health care treatment in detention. The submission from the NSW Commission for Children and Young People quotes children who say that no matter what they complained about, the treatment was 'water and panadol'. This view of treatment, as the NSW Commission for Children and Young People points out, 'is consistent with what immigration detainees have said for the last decade'⁽¹⁵⁴⁾, and was confirmed by interviews conducted by the Inquiry:

I had a tooth pain and they say just drink water. If the person had eye problem, drink water. Stomach problem, drink water. If you drink water 10 glasses, then drink 11. If we drink 11, then drink 12, 13. All the people sick, then drink water - nothing else. (Unaccompanied teenage boy)

I think the same treatment as everyone - water. Once I had a stomach ache and I was prescribed panadol and a few times headaches and general body pain and whenever I approached the medical staff I was told to drink water. (Unaccompanied teenage boy)⁽¹⁵⁵⁾

It is possible that complaints about water and Panadol may result from detainee misunderstandings of a diagnosis or from different cultural expectations of appropriate medical treatment. However, the prevalence of these comments among children is of concern, if only as a reflection of the level of mistrust which detainees had towards the primary health care they received in detention. Children in detention appear to have a strongly held perception that their illnesses were not being taken seriously, and that there were serious consequences. For example:

When we were in the detention centre and someone was sick, headache or sick, they would say, "Just drink water". The doctor said, "Drink water, three or four cups, and, if you don't get better, just drink more". My sister has a problem with her eyes. She said her eyes were so painful and she went to the doctor who said, "You just have to drink water". Now we come to Sydney and the doctor says she has a problem in her eyes ... (teenage girl)⁽¹⁵⁶⁾

These complaints also raise the concern that health problems were not identified and therefore not treated appropriately. Evidence from community groups assisting children after their release from detention suggests that there were several serious health problems identified after release that were not diagnosed and treated in detention:

There are a lot of congenital problems not diagnosed in detention centres and those extra months of lack of detection are delaying children's development. In the last 12 months:-

• two children with polio;
• several children with rickets;
• many children with developmental delays;
• many children with nutrition problems;
• many children with height and weight not appropriate for their age;
• many children with emotional problems, behaviour problems, bed wetting and indicators of depression;
• there have also been blood conditions.⁽¹⁵⁷⁾

Section 10.4.6 sets out some other claims that health problems in children were detected and treated only following release from detention.

ACM suggests that the identification of problems in detainees on release does not mean that a diagnosis did not occur. ACM also told the Inquiry that it did not always have the sufficient notice of a detainees release to allow for the transfer of medical records, which may indicate that a diagnosis did occur.⁽¹⁵⁸⁾ However, if it was the case that diagnosis did occur in detention, it raises issues about the quality of treatment provided in response.

Even allowing for the slow development of certain illnesses, and the difficulty of their early detection, the fact that serious health problems are quickly identified once children are released into the community suggests that the assessment and treatment procedures in detention were less than rigorous. Further, the health assessment of children in immigration detention may require a level of expertise not always available in the detention environment, as discussed in the following section.

(a) Findings regarding health assessment and treatment procedures

The Inquiry finds that there were processes in place for initial health assessments of detainees. However, those assessments failed to address the specific needs that child asylum seekers were likely to have. This may be related to the difficulties in recruiting staff with appropriate expertise (see section 10.4.2 below).

There was no routine testing of hearing and sight. The fact that some illnesses, eye problems in particular, were detected quickly following release from detention suggests that assessment and follow-up was not as systematic as it should have been.

10.4.2 Qualifications and expertise of ACM health staff

The Department's submission states that:

The Department requires [ACM] to ensure that health services are delivered by qualified, registered and appropriately trained health care professionals, and that they have appropriate expertise and experience to respond to the particular needs of detainees. The mix, expertise and qualifications of [ACM's] health services staff need to be appropriate to the detainee profile at each detention facility at any given time.⁽¹⁵⁹⁾

This suggests that the Department expected that health staff have the appropriate medical qualifications to address the special needs of detainees.

The evidence before the Inquiry suggests that medical staff in detention facilities had the appropriate formal medical qualifications in that they were properly registered. Moreover, some of the doctors and nurses encountered by the Inquiry appear to be highly professional and caring. However, the Inquiry is concerned that in order to provide the highest attainable standard of health care for asylum-seeking children, health staff may need specialised knowledge and experience. It has been difficult to ensure the appropriate mix of such expertise.

The Bollen Report found that:

Most of the remote rural detention centres have an ongoing problem recruiting and retaining staff with even basic qualifications and rarely have the opportunity to choose and obtain the right mix of medical personnel to reflect the population demographics.⁽¹⁶⁰⁾

Health staffing problems are also faced by rural and remote communities outside of detention. Therefore, it is not surprising that the location of detention centres in remote or rural areas limits the ability of ACM to attract appropriate health care experts.

(a) Paediatric experience of health staff

When children are detained, health professionals with paediatric experience should be available. The Department's submission suggests that it is of the view that ACM has met this criterion:

Facilities with children try to ensure that nursing or general practitioner staff have experience in paediatrics or child health.

The policies of [ACM] require that all new health staff attend a one-day formal orientation program addressing issues such as cultural awareness and sensitivity, managing detainees assessed to be at risk and child protection.⁽¹⁶¹⁾

However, in relation to paediatric experience, the Bollen Report found that:

Very few of the health care staff had paediatric experience ....Many of the centres will continue to be limited to recruiting those health care staff willing to work in a detention centre, particularly in a remote rural area. To address this inevitable deficiency, arrangements should be made with other service providers to provide short term input of more specialised services when required to fill any areas of deficiency.⁽¹⁶²⁾

The Bollen Report also recommends that '[a]t least some nurses should be trained in child health, midwifery, and psychiatry'.⁽¹⁶³⁾

The Inquiry heard evidence from one paediatric registrar who worked in Woomera for two short-term contracts of two weeks but is unaware of any other paediatricians who worked in the centres.⁽¹⁶⁴⁾ The Inquiry has not received any specific evidence suggesting that general practitioners with paediatric experience worked in the centres, nor does it have specific evidence about referrals to paediatricians, although this may have occurred. Evidence as to the availability of child psychologists is discussed in Chapter 9 on Mental Health.

A nurse who worked in Woomera in 1999 suggested that the absence of nurses with paediatric qualifications may have been problematic in conducting assessments:

We conducted medical assessments. It was by a three page document that had to be filled in. For instance ... none of us were experts in child development issues ... The children did not normally have access to a paediatrician who would do the normal milestones ... the only regular sort of assessment that we used for children was to do the weight and growth charts.⁽¹⁶⁵⁾

The Department has stated on the other hand that:

it needs to be remembered that most Australian children do not routinely have access to health professionals specialising in paediatrics. It is normal practice for a general practitioner to refer children to a paediatrician only if required. This normal practice is followed in detention facilities and medical practitioners refer children to paediatricians, as necessary.⁽¹⁶⁶⁾

However, when a child is detained for long periods of time, it is incumbent on the Department to ensure that the highest attainable standard of care is available to the detainees. Child detainees, particularly children with special health needs as many asylums seekers are, may require specialised medical assistance. Concerns about delays in accessing external health care, discussed later in this chapter, undermine any reliance on referrals to outside paediatric help.

(b) Cultural awareness of health staff

The level of cultural awareness of health staff impacts on the quality of health care provided to asylum-seeking children in detention. If a health care practitioner is not culturally aware, he or she may fail to identify the ailment of these children. This can occur for a variety of reasons.

For example, female children and mothers may feel it to be culturally inappropriate to recount their medical history to a male nurse or doctor. As the Bollen Report notes:

Women's health presents a problem in those centres with only male doctors. This creates a cultural problem for many female detainees who are unwilling, or whose husbands are unwilling for them to be examined by a male doctor. While many of the nurses at the detention centres are female, most nurses have no formal training in conducting a full clinical examination and making a diagnosis. This is an important cultural matter requiring resolution. It should be possible to arrange for a female medical officer to visit such detention centres on a regular basis to run women's health services ...⁽¹⁶⁷⁾

ACM reports, in June 2002, that it responded to this recommendation in the Bollen Report by ensuring that all centres have access to a female medical officer.⁽¹⁶⁸⁾

In addition to the specific cultural background of detainees, it must also be remembered that the trauma of travel and persecution can profoundly affect a child or parent's capacity to remember or determine what is relevant.⁽¹⁶⁹⁾ Moreover, the Inquiry heard that asylum seekers may be concerned not to reveal health problems that could affect their visa application.

Hence, in order to provide effective diagnosis and treatment it is essential for health staff to be aware of the culture and backgrounds of asylum-seeking children, and how this may affect detainee responses to health services. Specialised training can assist health staff to address such issues.

The Department states that it provided detention officer training to ACM staff entitled 'Cultural Diversity In Immigration Detention Facilities - A Resource Kit for Immigration Detention Service Providers' which gives 'basic information relevant to health professionals treating people from other cultures'. The kit includes small sections on health concerns for different cultural groups. The Department also states that it 'understands that ACM also conducts training for health staff that gives insights into cultural needs and differences'.⁽¹⁷⁰⁾ ACM states that:

health staff receive training on 'Barriers to Communication' skills and input on multicultural communication during their orientation program. Officers also receive an Induction Manual that addresses cultural issues. Officers also receive training sessions in working with families and children which have cultural content.⁽¹⁷¹⁾

It is unclear from the evidence before the Inquiry whether such training specifically addressed health issues; when such training commenced; whether it included all ACM staff; and whether it only took place at induction.

During the Inquiry's visits to Woomera in June 2002 health staff commented that there was no cultural training at all and that everything that they had learned was through the detainees.⁽¹⁷²⁾ Chapter 15 on Religion, Culture and Language discusses cultural training in more detail.

(c) Expertise in refugee health

In addition to cultural awareness, in order to promptly and appropriately treat detainee children medical staff should have some medical experience in diagnosing and treating ailments specific to children of particular backgrounds.

A doctor, who worked at Woomera from October 2000 to the end of June 2001, confirmed that asylum seekers suffered from ailments that were not common in Australia and for which the medical staff were not fully prepared:

There was severe diabetes, sugar-levels high, high - never seen before. There were heart diseases, murmurs. Many things we have never seen because we are such a developed country and these things are picked up when a child is born or blood-pressure is monitored. There were the chronic illnesses, asthma - severe asthma. Chronic illnesses.

Then there were the infectious diseases. The hepatitis Bs and Cs. The infections of the skins, scabies. You could see tracks of scabies under the skin, we had never seen before. Huge tropical sores, we have never seen before. It was a learning experience for all of us. I had to ring tropical medicines to find out the treatment and so on. And those were the tropical diseases. Intestinal parasites, we call them liver flukes and so on. Causing severe abdominal pain and so on.⁽¹⁷³⁾

The Department accepts that health care staff do not always have extensive experience in treating some of the diseases found in the detention population, but does not see this as a significant concern providing the medical staff can quickly access information about these diseases and modern treatment methods.⁽¹⁷⁴⁾However, there have been some concerns about access to such information. The Bollen Report recommended that detention facilities be better equipped with reference material regarding current medical treatments.⁽¹⁷⁵⁾ The Inquiry is pleased to note that in response to the Bollen recommendations, ACM audited its medical resources and ordered new reference material.⁽¹⁷⁶⁾

However, to the Inquiry's knowledge, training of ACM health staff did not include medical training in identifying common ailments in child asylum seekers.

(d) Findings regarding qualifications and expertise of ACM health staff

The Inquiry finds that while medical staff were generally available to children and their parents, the quality of care was compromised by the detention environment. A key difficulty appears to have been in recruiting sufficient medical staff, especially to remote areas, with the specialist qualifications necessary to meet the special needs of asylum-seeking children.

While it appears some efforts have been made to improve cultural responsiveness of medical staff, for example by providing some cultural training, the specifics of that training remain unclear to the Inquiry. Moreover, the Inquiry saw little evidence of specific and systematic paediatric or refugee health training for on-site health staff to help them address the special health issues facing asylum-seeking children. The Inquiry notes that parents who wish to see doctors with expertise in the community may seek advice from refugee and asylum seekers health networks, which can refer them to specialist doctors, often at no cost.

10.4.3 Availability of interpreters

The provision of on-site interpreters for the purpose of medical examinations appears to have been a persistent problem for the Department and ACM, in particular in Port Hedland.⁽¹⁷⁷⁾ The Department Manager at that facility reported an absence of on-site interpreters over a period of 19 months.⁽¹⁷⁸⁾ This is also acknowledged by ACM.⁽¹⁷⁹⁾ The failure to rectify this problem was the subject of a lengthy exchange during the hearings of the Inquiry.⁽¹⁸⁰⁾

During the Inquiry, Counsel assisting the Inquiry pointed the Department to the Performance Linked Fee Report for the December 2001 quarter which stated that:

There was a lack of on site interpreters at Port Hedland throughout the majority of 2001, this issue has serious implications in the sensitive area of induction and medical care and has been raised with ACM formally on many occasions including at COG and in correspondence. Whilst acknowledging the difficulties ACM had in attracting staff to Port Hedland DIMIA urges ACM to resolve this issue urgently and will apply sanctions for this quarter given the serious implications.⁽¹⁸¹⁾

The Department penalised ACM ten points for this breach. However, nine months later, the September 2002 Port Hedland Manager's report notes that the problem was continuing:

Unchanged from previous months

Lack of onsite interpreters, combined with the cramped conditions under which medical staff operate, means that lack of privacy continues to be a particular issue for residents attending the clinic.⁽¹⁸²⁾

ACM states that, with respect to the absence of on-site interpreters at Port Hedland during this period, the telephone interpreting service (the Commonwealth Government Translating and Interpreting Service, TIS) was still in operation. It also states that 'the Department eventually recognised and accepted the use of TIS and the penalty was subsequently removed'.⁽¹⁸³⁾

Although the use of the TIS may have addressed some of the difficulties faced by adults, the Department has acknowledged that TIS is unlikely to be appropriate for medical assessments involving children.⁽¹⁸⁴⁾ Moreover, it appears that at least during 2001 at Port Hedland, TIS was rarely used by medical staff.⁽¹⁸⁵⁾ The Bollen Report notes:

All centres have ready access to [TIS]. The majority of medical, nursing and mental health staff interviewed had difficulties with TIS, mainly because they found TIS difficult to access and using a speakerphone for interpreting, distracting or slow. Some staff used TIS regularly and without difficulty. Most staff preferred face-to face interpreters and asked that more interpreters ...be

dedicated to the health services ...Interpreters also contend that, if permitted, they could help staff understand cultural needs and differences that might assist staff in relating to detainees.⁽¹⁸⁶⁾

During its visit to the Cocos (Keeling) Islands facility, the Inquiry noted that there was only one phone for the entire facility (including staff) and therefore no practical access to TIS.

During the Inquiry's other detention centre visits in 2002, there did appear to be at least some interpreters available. Medical staff at Curtin reported to the Inquiry in June 2002 that interpreters are available for all medical appointments although they are short on female staff.⁽¹⁸⁷⁾ The Department informs the Inquiry that the situation with regard to interpreters has improved considerably. On-site interpreters are available at Port Hedland and Baxter, where many of the children are detained.⁽¹⁸⁸⁾

The absence of interpreters has a dual impact on children. The children who did not speak English found medical examinations to be an intimidating process. The children who did speak English often ended up interpreting for their parents, getting them involved in matters which were not their concern.

A doctor working at Woomera stated that the absence of an interpreter raised the obvious problem of a risk of an inaccurate diagnosis:

We had a lot of difficulty not being able to speak very good Farsi or Arabic, and most of the detainees had very little or no English. So there were often instances, and we were extremely alert to the possibility of children being abused by people in the centre. And I remember one specific instance when a seven or eight year old child was brought in screaming with blood pouring from his lip. And somebody said that he had been assaulted. Eventually we found an interpreter who was able to get the hysterical mother to explain that, no, he had been playing soccer and had tripped on the rocky ground and cut his mouth open on the ground, which was much more likely and something that we saw much more commonly.⁽¹⁸⁹⁾

The absence of interpreters during the triage process also created problems:

Well we certainly weren't able to see all of the people in the book when I was there and it wasn't a particularly good process because there is no interpreters available in the medical clinics so the detainee got into the nurse to ask to be seen by the doctor had to be - was done without the benefit of an interpreter. So often the problem that we thought we were seeing was completely different.⁽¹⁹⁰⁾

(a) Findings regarding the availability of interpreters

Although access to on-site interpreters may have improved, during the period of time covered by the Inquiry the provision of an adequate number of interpreters for medical examinations was a problem at several centres, particularly in Port Hedland from 2001 through to 2002. The shortage appeared to be related to difficulties in recruiting a sufficient number of appropriate interpreters to remote locations.

The TIS service may address some of the difficulties faced by adults, but it is not the most appropriate response to the needs of children in medical examinations. The shortage of interpreters for medical examinations likely exacerbated the difficulties of treating children and raised the risk of inaccurate diagnosis and treatment.

10.4.4 Access to ACM health staff

All immigration detention centres have health care staff available for medical treatment, including triage, nursing and first aid, although the hours of availability differ in each centre.⁽¹⁹¹⁾ Detainees who could not be treated by ACM nursing staff and doctors were referred to external specialists or hospitals.

In its submission to the Inquiry the Department provides a summary of health care services and facilities as at 31 January 2002, which listed the number of staff available on that day.⁽¹⁹²⁾ The Department also provided a comparative chart which indicates a higher doctor-population ratio in detention than in the general community. As the submission acknowledges, this is in order to address 'the special needs of people in detention, including the treatment of existing illnesses which were present at the time of arrival'.⁽¹⁹³⁾

However, evidence provided to the Inquiry suggests that, at least some of the time, the detention facilities were understaffed. ¹⁹⁴

The Bollen Report found that all 'health services regularly experience difficulties recruiting and retaining health staff'.⁽¹⁹⁵⁾

A doctor at Woomera for nine months ending June 2001 stated that

The workload was heavy. Very, very heavy. On 24 hours a day. We would get three or four calls through the night with regard to self-harm in the night.⁽¹⁹⁶⁾

Woomera health staff interviewed in June 2002 also stated that they were stretched with each employee working 120 hours every fortnight on a variety of shifts.⁽¹⁹⁷⁾

Port Hedland has also suffered from shortages at different periods of time.⁽¹⁹⁸⁾ The Bollen Report states that:

Until recently, Port Hedland IRPC had been unable to retain a permanent doctor and had relied on short term locums or used the local medical practice ...At one stage, Port Hedland relied on getting advice and having prescriptions faxed from the doctor at Curtin.⁽¹⁹⁹⁾

The Victorian Department of Human Services reports that children in Maribyrnong:

consistently stated that there were always more detainees needing to see medical professionals than there were doctors or nurses available to see them, and that at times, they were forced to wait for hours or on occasion, days, before being seen.⁽²⁰⁰⁾

A doctor at Woomera described the pressures on doctors to keep up with the caseload:

And we were never able to keep up with what was in the book because there was always emergencies that came in on top of the appointments that were booked but there was usually two doctors and you would get there in the morning and there would be a list of code numbers of people that we had to see - that we would see that day who would be called, one by one, over the loud speaker by their code number.⁽²⁰¹⁾

Triage processes are commonly used in hospitals in Australia as a means of relieving the pressure of demand on doctors and ensuring that the most needy patients receive appropriate treatment promptly. However, a nurse who formerly worked at Woomera noted that the triage process differed from normal community practice:

...normally, if people feel unwell, they decide to go to the doctor themselves. At the detention centre, they would have to see nurses and we would then refer the person to the doctor.⁽²⁰²⁾

A doctor stated that the process of having nurses filter the cases sometimes resulted in delayed treatment for children:

DR OZDOWSKI: So nurses constitute a barrier of access to medical practitioners? DR PFITZNER: In one way if you want to be negative, we could put it as a barrier; on the other way we could put it that we were almost over-worked and the nurses were trying to filter the severe cases to us. So I would like to put it in a positive manner, that this was done, but of course there were errors made and sometimes delay. And this particular child that I'm thinking of, there was some delay. I would have liked to see that particular child when the child had arrived with obvious physical defect, mental and physical defect. But I think I didn't see the child until the child had become, fitting or severe breathing problems for about four to six weeks, and I happened to see the child and the nurses treating it, and called the child up and then identified the severe defect.

So in ideal circumstances yes, that child should have been seen earlier than four to six weeks.⁽²⁰³⁾

An unaccompanied child recounted a situation where the problem went away before he managed to see the doctor:

I was sick there, I waited for one week to see the doctor. You have to put in a form, so by the time the doctor sees you, there's nothing wrong. I was sick with diarrhoea but by the time I saw the doctor he said 'what's wrong with you?' and I said 'nothing'. It was gone. He said 'you wrote me a letter to see you' and I said 'that was one week ago, I am better now'. If it was serious I could die in there.⁽²⁰⁴⁾

The Bollen Report noted several systemic problems with the triage process:

No centre had any agreed formal and documented criteria for referral. The triage process was unmonitored, had the potential for error, particularly in those centres with a high staff turnover of nurses with varied nursing experience and skills in primary care and triage.⁽²⁰⁵⁾

ACM reported in June 2002 that triage arrangements were reviewed by AUSeMED and in August 2002 ACM was developing training programs for health staff in triage.⁽²⁰⁶⁾

The Inquiry also heard that access to ACM health staff was controlled by detention guards. The medical centres were usually located in a different compound to the accommodation blocks. For security reasons, a guard was posted at the entrance to each compound. In some centres, this meant that children and their parents needed to ask permission from guards in order to go to the medical centre. The Inquiry heard allegations that this power was sometimes abused. A nurse formerly employed at Woomera stated that:

The ability of detainees to access the Medical Centre was compromised by ACM officers. Detainees were regularly turned away by ACM officers. On occasion, they were incorrectly told that the clinic was closed, that there were too many people at the clinic, or told that they were not sick and that they didn't need to see the doctor.⁽²⁰⁷⁾

The submission from National Legal Aid gave an example of the impact of this system:

At about 2am one very cold, wet night, the younger daughter's breathing became almost imperceptible. Her lips turned blue and she became limp and cold. Her father said he wrapped her in some bedding and carried her across an open area to the building where the medical office was located. Despite the father's protestations, the guard on duty at the building's reception area refused the father entry for half an hour. The father stood outside, trying to shield his daughter from the rain. He commented that this was one of the most cruel and demeaning experiences of his life. "My child and I were treated like stray dogs, left out in the cold. Can you imagine how hopeless I felt for my family, standing there shivering and wondering if my daughter would die in my arms?"⁽²⁰⁸⁾

(a) Findings regarding access to ACM health staff

The Inquiry acknowledges that, despite the efforts of on-site doctors and nurses, staffing shortages and the high demand for health services within detention at certain points in time, placed the health services under a great deal of pressure to meet the needs of children and their parents. The remote centres had difficulties recruiting and retaining staff, which further exacerbated these pressures.

The implementation of a triage system was introduced to address these difficulties; however, in some cases this resulted in delayed treatment. Further, access by detainees to health services was controlled by security staff on certain occasions. This controlled access contrasts to the open access to doctors by children in the community.

Irrespective of the operational difficulties faced by ACM and the Department with regard to health services, the Department has a responsibility to ensure that children receive medical attention in a prompt manner. Failure to do so in a detention environment can lead to unnecessary levels of stress, and delayed treatment.

10.4.5 Access to medication

The Department states that:

For children or their parents taking medication, supervision is considered necessary to preclude accumulation of toxic or life threatening doses of medication.⁽²⁰⁹⁾

Given the high levels of self-harm described in Chapter 9 on Mental Health, this would appear to be a sensible strategy in principle. However, it appears that it led to substantial delays in distribution of medication even when that medication could not be used for self-harm purposes. Further, it appears that there were other reasons why detainees were not permitted to self-administer medication. A nurse formerly employed at Woomera reported the following:

Detainees were not allowed to take medication to their accommodation blocks. This led to lengthy and inappropriate delays in the distribution of medication.

For example, in one instance a child with an ear infection had to represent four times a day for antibiotics that could only be distributed from the main Medical Centre because they required refrigeration. On one occasion the child and his mother had to queue for three hours in the rain at night to receive the medication, as there was only ever one nurse on duty at night. This caused the child and the mother great distress.

This example is one of many where detainees and their children had to queue for hours at night to receive medication.⁽²¹⁰⁾

Moreover, this example indicates how waiting for medication can cause great distress to children, particularly at night.

A former detainee child also pointed out that the shortage of staff made the process very difficult:

They will give you a slip type thing that says you have to come 3 times a day, to get your tablet, but there is one nurse - how can you?⁽²¹¹⁾

Another child stated that he had to wait two hours to receive medication.⁽²¹²⁾

(a) Findings regarding access to medication

It is understandable that the Department and ACM are reluctant to allow detainees to self-administer medication for fear of self-harm. However, the Inquiry is concerned that the blanket policy of controlling medication distribution resulted in some children experiencing unnecessary delays in obtaining their prescribed medication. This caused considerable distress.

10.4.6 Access to external doctors and hospitals

The medical centres within the detention facilities are only intended to provide primary care. The Department's submission states that:

Detainees who cannot be treated within the detention facility are referred to off-site specialists, hospitals or other institutions for ongoing care.⁽²¹³⁾

The Bollen Report states that '[d]etainees can be referred to other health services when required' but that the remoteness of the facilities results in delays and 'health staff frequently encounter difficulties in obtaining specialist appointments'.⁽²¹⁴⁾Furthermore, the Bollen Report notes that in 2001:

The IRPCs, because of their location, do not have ready access to emergency services including surgical, obstetric, dental and psychiatric services nor the ready availability of consultants to offer the necessary backup to the primary care service providers. Arrangements for provision of secondary care services for IRPCs are inconsistent and require innovative approaches to enable detainees and their primary care providers to have the level of support consistent with that available to the Australian community. Some innovations are being trialled, including videoconferencing for psychiatric diagnosis and management. However, a range of specialist health care consultants should be engaged and funded to provide readily available telephone advice to IRPC medical staff.⁽²¹⁵⁾

Most health staff in the detention facilities were of the view that when children required specialist treatment or hospitalisation those services were generally provided. The Department has provided some examples of health treatment given to detainees, such as:

• in excess of $9000 was spent treating a child suffering from tuberculosis
• $920 was spent providing occupational therapy to a child.⁽²¹⁶⁾

However, the Inquiry heard some examples of children waiting substantial periods of time before being referred to external services. The most serious examples occurred with respect to children with disabilities. This is addressed in the following chapter.

The Inquiry also heard several examples relating to eye problems. For instance, an unaccompanied child in Curtin saw a doctor for visa purposes shortly after his arrival in May 2002. The doctor noted that he had previously had lens replacement surgery and that there should be 'further investigation diagnosis and management of these conditions'.⁽²¹⁷⁾ A month later, the ACM medical records note that the boy asked to be put on the optometrist's list and this was done four days later.⁽²¹⁸⁾ However, there is no record of any follow-up on his eye condition, as suggested by the previous doctor, nor whether he saw an optometrist. The Inquiry understands that the boy underwent substantial restorative eye surgery after he was released from detention.

Another unaccompanied child described how he had an appointment with an eye specialist but was not collected for the appointment:

I have an eyes problem. I have missed an appointment. It was their responsibility to tell me I was going to a doctor but there was a school excursion that day ... I had this problem in Afghanistan, I never saw a doctor. Still I can't see with this eye, just with this one.⁽²¹⁹⁾

The Victorian Department of Human Services found that:

...several unattached minors were assessed as requiring corrective glasses soon after their release into Victoria. Another young person was found to have a severe hearing loss and required a hearing aid.⁽²²⁰⁾

The Curtin Department Manager report for March 2002 notes that:

A number of cases came to notice during the month where ACM were not providing glasses for detainees who required them. This has now been rectified.⁽²²¹⁾

One child alleged that he had serious kidney problems that were never seen to by a specialist:

I have got a kidney problem in both kidneys and I suffered a lot with that in the camp. I was having this pain and they were telling me to drink water. Any sickness or any pain we were told to drink water. Very little painkillers. Altogether five or six times I was ill. My older brother lobbied a lot for me to be sent to a doctor. One night I was very sick and he felt I should see a doctor but they gave me two panadol and told me to drink water. (Unaccompanied teenage boy)⁽²²²⁾

The Inquiry does not have evidence why delays in referrals to external treatment occurred in these particular cases.

However, some concern was expressed to the Inquiry about the difficulties encountered by doctors when referring patients to external doctors and hospitals.

Firstly, the isolation of some of the centres placed added pressures on doctors as it was not as easy to access specialists to assist them in their diagnosis and treatment:

Yes, with regard to working in the hospital you would be less stressed because you have powers of your colleagues, peers and seniors to relate to, to discuss, to give you a sense that you are doing things the right way. When I was there I was the only medical officer except for a part-time. We used to discuss but we had difficulty referring to our specialists. Skin specialists, mental specialists and other infectious diseases specialists. So, in that way we were more pressured with regard to letting us know whether we were doing the right thing. We checked constantly but the people were not on tap.⁽²²³⁾

The distance of some of the centres from metropolitan areas may also have forced doctors to make more dramatic referral decisions than might otherwise have been necessary:

[T]his was part of the problem of being located where the centre is, so far away from any other form of civilisation, is that there was no in between, between what we were able to do in the medical clinic and essentially a patient being seen in a tertiary hospital in Adelaide. Which was not only expensive but a cumbersome arrangement and not always completely necessary. Something half way would have been adequate for a lot of people, but we just didn't have that option that we would have if the centre was located closer to civilisation.⁽²²⁴⁾

ACM, in its response to the draft of this report, acknowledges that the location and corresponding limited availability of medical services may have been frustrating for medical practitioners in the remote centres.⁽²²⁵⁾

Secondly, the Inquiry also heard a number of suggestions that cost was a consideration in the decision to transfer a detainee to external health treatment. For example, the Inquiry heard from one doctor as follows:

DR CARROLL ...So if we needed to transfer somebody to another hospital or to another setting, we had to get permission from the [ACM] Health Services Manager (a nurse), who had to get permission from the organisational people, and I don't know how much of that was ACM and how much was DIMIA. I mean we were constantly reminded that the operation was a financial one and that we had to try and make savings or not increase costs where that could be avoided.

DR OZDOWSKI: In your normal practice would you make similar considerations? Would you make similar choices?

DR CARROLL: No. Well, not on the same scale, no. I mean working in a public hospital setting, things are done when they need to be done as long as that is feasible. I wasn't used to being told that things shouldn't be done in order to save money, no. Not in terms of direct patient welfare.⁽²²⁶⁾

The Western Australian Government also stated they believed that there had been some reluctance to provide care to a child in Curtin because of the cost, although this situation was eventually resolved:

there was a situation in which referral of an adolescent in detention was made to the North West Mental Health Service, which is based in Broome. The adolescent was assessed and the result of that was a recommendation as to a particular treatment program. My understanding is that there were some discussions and negotiations about the cost of providing that particular treatment approach for that adolescent. But at the end of the day, best practice was what was followed and the adolescent was actually instituted with that treatment program.⁽²²⁷⁾

However, not all doctors were of the view that cost was a consideration:

In terms of physical health, I was of the view that children received appropriate levels of care at the WIRPC when I was working there. I did not think that medical care was denied on the basis of cost. In my opinion it was always available when it was pressed for.⁽²²⁸⁾

ACM denies that payment arrangements between ACM and the Department impacted on the provision of health services in detention centres. However, it suggests that Dr Carroll's evidence cited above 'appears to confuse the need for legislative authority from DIMIA to remove a detainee with authority to pay for relevant treatment'.⁽²²⁹⁾

The Inquiry did not receive any evidence that access to external treatment was actually denied to a child detainee because of cost considerations nor that this was a consistent instruction to medical staff. However, ACM's comments and the doctor's claims raise the issue as to whether the procedures were sufficiently clear to assure doctors that cost was not an issue.

Thirdly, it appears that in order to ensure the speedy transfer of patients to external treatment, doctors were required to take extra measures to propel the process:

I think it was up to the nurses and the medical officer if there was a severe problem. I would myself go down and say, you know, "This person needs to go". I'd speak to the DIMIA officer to get the release to go to the hospital, because that was a financial commitment there. And then go to ACM and say, "Let's get a car and guards and whatever is needed to go down," and ring the hospital and make the appointments. So all our medical role did not only refer to medical diagnosis. If we wanted the thing to progress it was up to the doctor and the nurse, and I took that task on, to actually go and push the thing through.

So it may be some of the other doctors may have felt their task was just medical, and just referred and hoped that it percolated through. In my experience if that was done, and I don't know, the progress would be very slow. And I would myself go and see the DIMIA staff, the DIMIA director, go and see the ACM staff, the ACM manager, to get all those things together. It was a very huge logistic operation, because you had to get permission, then you have to ring the hospital to make sure that the child would be received, and then the whole thing would progress.⁽²³⁰⁾

The Inquiry recognises that many of these witnesses are commenting on the period of 2000 to early 2002. However, it appears that the procedure for making referrals and transferring to hospitals was unclear as recently as June 2002, when ACM noted that:

To date there has been no discussion with DIMIA regarding criteria for access to health services for detainees. ACM continues to welcome the opportunity to work with DIMIA, relevant community agencies and the proposed Health Advisory Panel (HAP) to develop guidelines for secondary and tertiary referrals based on clinical status, length of time in detention and age and sex of the detainee.⁽²³¹⁾

The controlled access to specialists and hospitals for children in detention marks a significant distinction to the free access available to children in the community.

(a) Findings regarding access to external doctors and hospitals

There were no specific allegations that treatment was denied to a child because of the system of external referral. However, it appears that unclear procedures and the location of remote centres led to long delays in accessing the appropriate secondary care at various times. The Bollen Report suggests that the result was a lower level of care than in the Australian community. The Inquiry is particularly concerned by the restricted access to external health care experienced by some children with disabilities, as discussed in the following chapter, and children with eye problems discussed above.

The use of short-term contracts for medical practitioners in detention facilities means that it is extremely important to have clear and easy referral procedures regarding external specialists and hospital care. The Inquiry finds that this has not been the case.

There is insufficient evidence to suggest that cost concerns were generally a barrier to accessing external health care, although at least one doctor had the perception that this was the case.

10.4.7 Hospitalisation and contact between families

Detention means that family members do not have the same freedom to choose when to visit or accompany parents or children in hospital as they would if they lived in the Australian community. Thus, where a child or parent is hospitalised, it is incumbent on the Department and ACM to ensure that there is appropriate contact between family members.

The evidence received by the Inquiry suggests that generally when a detainee child requires hospitalisation, at least one parent is given the opportunity to accompany the child to hospital.⁽²³²⁾ This includes cases which require air transport. The Inquiry met a family where hospitalisation meant that for a month, one child was in hospital in a capital city, the mother was in a motel near the hospital and the father and the other children were in a remote detention centre.⁽²³³⁾

On the other hand, the Inquiry also received evidence that on one occasion, at least, parents were restricted in the amount of time they could spend with the child in hospital:

An Iraqi family of four had been in another IDC for six months when the father and his six-year-old son were transferred to Maribyrnong to obtain medical treatment for the child suffering from a heart condition. The mother and two-year-old son remained in the other IDC. The father was distressed about the family's separation, particularly as his wife was diabetic and three months pregnant.

The child, who could not speak English, was hospitalised for approximately two weeks. During this period, two ACM officers escorted the father to the hospital to visit his son for one hour each day. The father was frustrated and angry that he could not remain with his son in the hospital for longer periods.

The family was separated for six weeks before the father and son were returned to the other IDC and reunited with the other members of the family.⁽²³⁴⁾

The Department states that the restricted visiting hours were 'certainly not a condition imposed by ACM'.⁽²³⁵⁾ It is possible that the hospital restricted visiting hours, presumably a condition which would be applied to all hospital patients. However, it seems unusual for the hospital to restrict parental visits to one hour a day, even for a very sick child, especially when the child does not speak any English.

The Inquiry also heard a number of examples when parents have been hospitalised, leaving children behind in the detention centre. For example an Iranian mother and her seven-year-old child were separated from each other for five and a half weeks after the mother attempted suicide in their fifteenth month of detention at Woomera.⁽²³⁶⁾

Generally, arrangements are made for children to visit their parents during this time, although only in rare cases are children given the option of moving into or close to the hospital with the parent.⁽²³⁷⁾ For example, the father of an 11-year-old boy at Woomera was hospitalised several times in 2002. At one point both parents were in hospital and ACM granted the child access to them after school in order to maintain the family unit as much as possible.⁽²³⁸⁾ The child visited his father in hospital daily.⁽²³⁹⁾

However, the Inquiry received some evidence that, at Woomera at least, the frequency of the visits by children were restricted to times convenient for the detention centre. Some children with parents in hospital complained to the Inquiry that they were only allowed to visit the hospital on weekends. ACM claims that there is no evidence to suggest that ACM restricted children in visiting their parents in hospital or contacting their parents by phone.⁽²⁴⁰⁾ The Department also 'strongly rejects' any allegation that they deliberately restricted phone calls and visits by children.

However, ACM's records show that a 12-year-old boy climbed on the razor wire fence and slashed himself stating that he wanted to see his mother in hospital. ACM said that the visit would be arranged 'as soon as possible'⁽²⁴¹⁾ and the records show that it happened six days later.⁽²⁴²⁾

The 12-year-old boy and his sibling were permitted to visit their mother twice a week, on Saturdays and Sundays only. However, contrary to the Department and ACM's assertions, it appears that children were not allowed to telephone their parents whenever they liked. For example, on one occasion the son in this family asked if he could call his mother and was refused permission because 'he had one [call] yesterday'.⁽²⁴³⁾

(a) Findings regarding hospitalisation and contact between families

The Inquiry finds that generally the Department and ACM made efforts to ensure that children and their parents were able to maintain contact with each other during periods of hospitalisation. When a child was hospitalised, one parent usually accompanied the child to hospital or visited on a regular basis. However, when a parent was hospitalised the children generally remained in detention. Either way, children in detention did not have the same freedom of access as children in the community.

The separation of parents and their children can have an impact on the health of children remaining in the detention centre as well as on the child or parent in hospital. This issue is discussed further in Chapter 9 on Mental Health (section 9.3.4) and Chapter 14 on Unaccompanied Children (section 14.6).

10.4.8 Access to pre and postnatal care

Between 1 January 1999 and 26 December 2003, 71 babies were born in detention to unauthorised boat arrival mothers.⁽²⁴⁴⁾ The evidence received by the Inquiry suggests that as a general rule prenatal and postnatal services were provided to pregnant women.

However, the Inquiry received some evidence that communication difficulties in postnatal care, including lack of access to an interpreter, were problematic in one case raised with the Inquiry. The example raised by the Australian Association for Infant Mental Health (AAIMH) suggests that a woman had a caesarean without consent and inadequate postnatal care.⁽²⁴⁵⁾ The South Australian Department of Human Services examined the circumstances in this case and reported the following:

Mother was taken to Port Augusta because of her pregnancy. She remained in hospital for 20 days, after 15 days she had a caesarean. She is unclear why she was to have this procedure as [it] wasn't term and there were no signs of labour. She alleges she had no regular access to an interpreter, only telephone access upon medical request. She was supervised 24 hours by ACM staff. She describes feelings of powerlessness and isolation while in the hospital. She had little contact with her family. She says she went on hunger strike while in the hospital, due to her frustration regarding lack of communication with family and issues around the birth ...

The mother experienced bleeding on the third day back in Woomera, it was recommended she be admitted to hospital, she refused admission. She threatened to kill herself if she was forced to be re-admitted. The baby ... has not had the recommended 6 week postnatal checks.⁽²⁴⁶⁾

The Minister publicly responded to this allegation in November 2002 by restating Departmental policy on the treatment of pregnant women, although not refuting the specific claims.⁽²⁴⁷⁾ The Department's response states that the responsibility for communication and interpreting on medical treatment while in hospital lies with the State authority.⁽²⁴⁸⁾

ACM states that its staff had no influence over the decision to perform a caesarean section. ACM also asserts that the woman had access to a competent postnatal check up by a female doctor attending the centre. The doctor did not recommend a return to hospital. ACM adds that the Health Services Coordinator at the time was an Early Childhood Nurse with extensive experience running a Baby Health Clinic.⁽²⁴⁹⁾

This case highlights the critical links between the mother's mental health, the health of a newborn baby, and the need for adequate communication. An example of the difficulty in dealing with postnatal depression in detention is discussed in section

9.3.4 in Chapter 9 on Mental Health.

The Inquiry also heard concerns about the re-location of pregnant women in remote detention centres to city hospitals at 36 weeks, sometimes without their husbands.

The AAIMH describes the impact of early transfer to hospital as follows:

...this is a practice that seemed to be best practice in obstetric care in rural and remote areas, so it just does not apply to women in immigration detention. Unfortunately the problems of language and understanding about obstetric care are seen to be very lacking in terms of the antenatal care for women in detention centres and I think the recommendation is that women consent - are fully aware of their options in terms of giving birth and fully consent to those options so that they are not traumatised further by separations from their families, of which they know no reason for.⁽²⁵⁰⁾

The Bollen Report also comments that this practice is 'both unnecessary and expensive'.⁽²⁵¹⁾

On the other hand, a doctor at Woomera was of the view that this was best practice, albeit with associated difficulties:

DR OZDOWSKI: From what you said it appears that women were spending a relatively longer period of time in Port Augusta Hospital, usually as I understand a woman would go a day or two days before birth and in the case of Woomera they went substantial periods of time in advance to the hospital. Were they told, were they explained the reasons for it?

DR PFITZNER: Yes. I don't think they were sent for any greater length of time compared to the other women in the South Australian community. It is the set procedure in the country because there were not obstetricians available easily, that they went to a specific hospital, in this case it was Port Augusta Hospital, to be looked after and that was at 36 weeks until their delivery which is, you know they stayed about four weeks, and this was normal procedure. My understanding is that they were involved in being informed as to why they were there for four weeks. The only difficulty was that the husband may not have been able to go with mother because the husband had to stay back and look after the other children that were left at the detention centre and although we did advocate that the husband and the rest of the family might go and stay at Port Augusta this was not able to be done because of financial or logistic reasons.⁽²⁵²⁾

While the Inquiry did not hear evidence that the quality of the care provided was inferior as a result of re-location, it notes that detainee women are likely to have significant language and cultural barriers which may require greater support during the birthing process. Yet they cannot choose someone, such as their husband, to support them at the birth during that time. They may also be separated from their other children for a prolonged period of time during this process, unlike women detained in the city centres.

As a general rule, it appears that detainee children and fathers were not permitted to accompany their mothers/wives to the place where they gave birth. In one case, ACM, 'as a measure of good will', approved the visit by a husband to his wife who had already given birth in Port Augusta Hospital.⁽²⁵³⁾

In its submission, the Department cites an example where a child accompanied her mother to an accommodation unit close to a hospital for the last four weeks of her mother's pregnancy, and then visited the hospital regularly after the birth.⁽²⁵⁴⁾However, as described above, in the case of one family, there was separation for several weeks.⁽²⁵⁵⁾ This same mother had another child in detention. Following the birth, the entire family was housed in an Adelaide motel for several weeks.⁽²⁵⁶⁾

An ACM employee, who worked at Curtin for more than two years, first as a nurse and later as Health Services Manager, told the Inquiry that:

My days with ACM were finally numbered when I was posted to Christmas Island. While there I refused to be the escort nurse for two pregnant women who were being forcibly separated from their husbands and children so that they could be taken to the mainland to have their babies. Their families were not allowed to accompany them because once on the Australian mainland they would be able to apply for a visa. Breaking up families meant that the wife would voluntarily leave the mainland to reunite with her family. These ladies would. Especially because while on the mainland they are kept in isolation from other detainees. They were also not told their legal rights.⁽²⁵⁷⁾

ACM comments that it had no control over the need to move women to regional hospitals in these circumstances. It had no control over the location of the detention centres, nor the availability of services in these areas. In such a circumstance, it claims that 'the logistics involved in transferring entire families from remote locations makes this option non-viable'. However, 'ACM makes every effort to ensure that family members have open lines of communication when mothers are hospitalised prior to giving birth'.⁽²⁵⁸⁾

While the remote location makes it more expensive to keep a family together during the weeks before a child's birth, the Inquiry notes that, as indicated in the more recent examples given above, it is not impossible for the whole family to be transferred close to the hospital, even if logistically difficult.

(a) Findings regarding access to pre and postnatal care

While the Inquiry believes that efforts have been made to provide pre and postnatal care to women and their babies in detention, it is concerned that the restrictions that come with detention in remote areas and the shortage of interpreters made the process unduly traumatic for pregnant women.

Although the performance of a caesarean operation may have been necessary in the case highlighted above, it is concerning that a woman received the operation without properly understanding the procedure. It is irrelevant whether ACM or the State authorities were directly responsible for providing adequate interpreter services because it is ultimately the Commonwealth's responsibility to ensure that women receive the highest attainable birth care.

The Inquiry also notes that although it may be commonplace for families in the community in remote areas to be separated during a period of confinement, unlike detainees they are free to make the decision to move close to the hospital during that period of time, pending financial and other personal considerations. Women detainees, on the other hand, are restricted in this choice. As discussed in the previous sections, this separation can cause children extreme anxiety and stress. Further, these women are especially vulnerable due to language and cultural barriers as well as a complete unfamiliarity with the Australian medical system.

10.4.9 Access to dental care

Dental care is particularly important for asylum-seeking children who are likely to have had low levels of nutrition and dental care in their countries of origin. Consequently there is a huge demand for dental services by detainee children.

The Department states that:

Dental health care is provided for the preservation of dental health, and where physical health may be jeopardised as a result of a dental condition. Dental services for children and adult detainees are not provided for cosmetic purposes ...Dentists visit regularly ...⁽²⁵⁹⁾

The Bollen Report found that '[a]ll centres reported managing demand for dental services as a major problem'.⁽²⁶⁰⁾ The Bollen Report recognised that access to dentists was a problem for the Australian community generally but also found that 'there is a high incidence of severe dental caries, dental abscesses and gum disease amongst detainees'.⁽²⁶¹⁾ As a result when dentists were called in to the centres, they spent all their time on pain relief, with no time left for the conservative care required by children:

For the remote centres, ACM has contracted a dentist who will fly in when required, but generally every 4-6 weeks. I was told that the dentist sees 4060 detainees daily at each visit, sometimes working for more than 12 hours each day, mainly to provide management of pain and infection. Because of the extent of dental pathology, most treatment is extraACction. Given the time available for each patient, and the extent of dental pathology, it is unlikely that much conservative dentistry could be practised.⁽²⁶²⁾

A child told the Inquiry that he complained of problems with his teeth but never saw a dentist:

I told them about my teeth, that I had some difficulties and had some problems there. I told them about my breath that it was very bad because of my teeth and needed some attention. They didn't even care about that.⁽²⁶³⁾

ACM notes that in December 2001, children in Woomera were assessed for their teeth and gums by a visiting dentist.⁽²⁶⁴⁾ In May 2002, a local dental practice offered to provide services to Woomera.⁽²⁶⁵⁾ It is unclear whether this offer was taken up and whether children were given appointments for preventative work.

In June 2002, ACM stated that it was in the process of developing guidelines for the provision of dental care for children.⁽²⁶⁶⁾ While the Inquiry has not been provided with a copy of those guidelines, it does appear that some steps were taken to improve the provision of dental care in detention. For example, in July 2002, the Department Manager at Curtin reported that:

During July the Health Services Coordinator was able (after much difficulty) to bring a dentist on site to do a preliminary examination of most detainees from which he could prioritise cases and appointments made.⁽²⁶⁷⁾

ACM also informs the Inquiry that it provided dental health education on correct brushing and eating appropriate foods, although it is unclear how often that occurred, when it commenced and at which centres it took place.⁽²⁶⁸⁾

However, in August 2002 the Curtin Department Manager comments that 'dental care still remains an issue for detainees but ACM have ongoing visits to the dentist in Broome'.⁽²⁶⁹⁾

During the Inquiry's visit to Baxter in December 2002, staff reported that persons who had been in detention for two years were now entitled to a wider range of dental services.⁽²⁷⁰⁾ It is to be hoped that, as a general rule, children would not need to wait two years in detention before seeing a dentist for conservative work.

The Inquiry is aware that many children in the community find it difficult to access preventative dental care. However, by taking children into detention the Department assumes a higher duty of care in order to provide the 'highest attainable standard of health' to those children. The longer children are in detention the higher the responsibility to ensure not just restorative but preventative care for children. As the Bollen Report notes: '[p]oor dental health may have a significant impact on general health and nutrition'.⁽²⁷¹⁾

(a) Findings regarding access to dental care

The Inquiry finds that the dental care provided to children detained for long periods of time has been inadequate. The initial policy of providing emergency dental care may have been sufficient for children detained for short periods. However, when children are detained for long periods they will require preventative as well as recovery work. This is especially the case in light of the high incidence of dental health problems among the detainee population.

10.4.10 Immunisation

The Department's submission states that since November 2000 all children in detention are offered immunisation based on the Australian Standard Vaccination Schedule. All immunisation is voluntary but if parents do choose to have their children vaccinated, ACM 'provides each detainee on discharge with a record of all immunisations given during detention'.⁽²⁷²⁾

The Inquiry has received conflicting evidence on the regularity with which immunisations were provided to children. This may partly have been the result of staffing issues. ACM states that immunisation is undertaken by either qualified nurse practitioners in immunisation or medical practitioners. However, it appears that when there were no qualified nurse practitioners in immunisation, there were delays.

For example, the Bollen Report states that:

The ability to immunise within one week of arrival is dependent on having the staff including interpreters to fulfil this requirement. Nurses providing immunisation must hold either an immunisation certificate or work under the supervision of a doctor. Lack of staff members with immunisation certificates in some centres has resulted in inevitable delays in meeting the DIMIA and public health requirements for immunisation ....Staff had experienced difficulties gaining informed consent from parents who do not speak English, because of the scarcity of interpreters.⁽²⁷³⁾

A doctor at Woomera expressed the following concerns about the process for ensuring the immunisation of children as at June 2001:

I was not able to get an appropriate programme in place for immunisation. Again this was because of a dispute between SA Department of Child and Youth Health and the Commonwealth about who would pay for this. Nurses at the WIRPC lacked the training or confidence to perform immunisation so I therefore tried to immunise children myself. I was critical of the failure to properly immunise children as it was important not only in the immediate individual case but also for when the child was released in to the community.⁽²⁷⁴⁾

However, it appears that in that same month, Child and Youth Health Services from Adelaide visited to advise ACM on and provide immunisation for under-16s.⁽²⁷⁵⁾ In September 2001 ACM notes that two of the health staff were focused on improving immunisation status of young detainees but there is 'still more catching up to do'.⁽²⁷⁶⁾

A witness from the New Arrivals Clinic in Adelaide stated that from the end of 2001 systems had been implemented to ensure the full immunisation schedule was carried out:

To the best of my knowledge, at the moment children have been given full immunisation services. This was not always the case. I believe originally they were only offered oral polio vaccine and measles, mumps and rubella. That has changed since, I believe last year.⁽²⁷⁷⁾

Nevertheless, it appears that this witness based her statements on the assumption that the South Australian Immunisation Unit was providing the vaccinations.⁽²⁷⁸⁾Another witness stated that this service was only provided on two discrete occasions and was not an ongoing program.⁽²⁷⁹⁾

In May 2002, the Department investigated allegations made by a nurse that 'the vaccine register is often incomplete for children' on their release from Woomera.⁽²⁸⁰⁾The investigation found that South Australian Immunisation Unit 'has confirmed that it had no concerns about the immunisation program or reporting' at Woomera.⁽²⁸¹⁾Nevertheless, in July 2002, ACM notes that it continued to monitor immunisation levels.⁽²⁸²⁾

A nurse who had conducted a research paper on immunisation in Australian detention facilities found that:

children that were born while in detention were put on to the Australian vaccination schedule, but those that arrived were not and they were put on a small catch-up schedule that may not have covered them for all the diseases that we protect against.⁽²⁸³⁾

In August 2002, ACM notes that at Curtin IRPC, children's 'catch-up' vaccinations continued.⁽²⁸⁴⁾ There are also records of immunisations being given to children in February 2001 and December 2001.⁽²⁸⁵⁾

Hence it appears that immunisation occurred at detention centres at various times over the period covered by the Inquiry, but that not all children were sufficiently covered by the program by the time of release. ACM explains this discrepancy on the basis that people's release from detention did not match the designated schedule for immunisation, which requires an appropriate time gap between doses.⁽²⁸⁶⁾

Evidence on whether children and parents had the appropriate vaccination records on release during the period covered by the Inquiry is not conclusive. It appears that 'some of them do, some of them don't'.⁽²⁸⁷⁾ The Department states that it is aware of the allegations that detainee vaccination records were not adequately maintained but adds that ACM has confirmed that these problems were resolved by early 2002.⁽²⁸⁸⁾

Where records were provided, some are of poor quality:

the records that I have seen have just been written up very briefly and they haven't often numbered the dose number to whether it's dose 3 of OPB that they've been given or dose 4 or 5, or dose 1 of MMR or dose 2 so it's just poor documentation.⁽²⁸⁹⁾

Immunisation nurses in the community state that where children do not have the appropriate records they assume that none are done and start from the beginning.⁽²⁹⁰⁾

(a) Findings regarding immunisation

The evidence regarding the immunisation scheme over the period covered by the Inquiry is inconclusive. However, it does appear that at certain periods of time immunisations were given, and that newborn infants were appropriately immunised.

10.4.11 Medical records

The Department provided the Inquiry with a great number of medical records created by ACM health staff. The level of detail and currency of the medical logs of ACM doctors and nurses appear to have been of a high quality. However, there is some concern as to whether the same level of record-keeping was maintained with respect to recommendations of external specialists.

Several service providers to children in the community state that children released from detention were either not properly diagnosed, or the diagnoses were not properly communicated in order to facilitate continuity of health care. For example, the South Australian Department of Human Services states that:

The health worker reports that there are often significant physical health issues that appear to be undiagnosed or formal communication not provided on these conditions, if previously diagnosed in detention. Conditions such as poliomyelitis, haemiplegia, ricketts, blood and infectious disorders have been diagnosed in children following their release into the community. The health workers indicated that many of these children would have benefited from earlier interventions or the communication of medical information if such interventions had been in place.⁽²⁹¹⁾

The Victorian Department for Human Services found that many unaccompanied children were found to have hearing and sight problems on release:

As a consequence, it has become general RMP [Refugee Minor Program] practice to ensure that unaccompanied minors newly released from detention receive a full medical assessment and any identified medical issues are followed up.⁽²⁹²⁾

Regarding the transfer of medical information on release of detainees, the Department states that:

The detention services provider is required to ensure that upon discharge all detainees are provided with a copy of medical treatments received in immigration detention. While the Department accepts that in the past there have been issues with the provision of discharge summaries, the detention services provider has advised that new procedures were implemented to ensure that all ex-detainees are now provided with summaries of medical treatment received while in immigration detention.⁽²⁹³⁾

The Inquiry did not receive any evidence on new procedures in this regard. ACM identifies two difficulties with carrying out this 'procedure'. Firstly, it is difficult to transfer medical information when releases occur suddenly without opportunity for summaries to be provided. Secondly, full medical records for detainees remain the property of the Department and when detainees are released their medical records are returned and archived with the Department.⁽²⁹⁴⁾

(a) Findings regarding medical records

The Inquiry finds that the medical logs kept by ACM doctors and nurses were of high quality. However, the integration of specialists' recommendations and the provision of records on release appear to be wanting. The contradictory evidence of ACM and the Department indicates a lack of clarity regarding any procedure to ensure that medical information is transferred to child detainees and their families on release. This may have implications for the proper diagnosis and treatment of children when they are released from detention.

10.5 Summary of findings regarding the right to health for children in detention

The Inquiry finds that there has been a breach of articles 22(1), 24(1) and 39 of the CRC. The Inquiry's findings in relation to articles 3(1), 6(2) and 37(c) are set out in more detail in Chapter 17, Major Findings and Recommendations.

Australia's mandatory detention laws result in the long-term detention of children, which creates inherent difficulties for the provision of an adequate standard of health care. However, the Department has a responsibility to ensure that the health needs of children are addressed, within the confines of Australia's laws, in a manner that ensures the protection of their rights under the CRC. The Inquiry finds that the Department failed to fulfil that responsibility for the reasons set out below.

The Inquiry acknowledges the efforts that the Department and ACM have made to provide children with health services and recognises that there have been improvements over time. In particular, the Inquiry notes that an independent review of health services (the Bollen Report) was commissioned by the Department in October 2001 in order to improve the detention health system. While noting that it took some time to undertake this review, the Inquiry commends the Department for this initiative and ACM for its efforts to respond to the recommendations throughout 2002. Furthermore, it is clear that individual staff members sought to provide the best health care possible in the circumstances.

However, the standard required by the CRC in relation to health is 'the highest attainable standard'. The Inquiry finds that the circumstances within which health staff had to operate prevented children in remote detention centres from enjoying 'the highest attainable standard of health' available in Australia, and from accessing the facilities necessary to achieve those standards (article 24(1)). This is especially the case taking into account the special needs of children seeking asylum (recognised by article 22(1)) and the obligation to take 'all appropriate measures to promote physical and psychological recovery ... in an environment which fosters the health, self-respect and dignity of the child' (article 39).

Unlike children in the community, children and their families in detention are unable to choose the environment in which they live and the health care that they receive. As a consequence children and their families rely on the Department and ACM to provide the environment, facilities and services necessary for children to enjoy the highest attainable standard of health.

The first problem arises from the physical detention environment itself, particularly in the remote detention facilities. The extreme climate and physical surroundings of the remote centres caused children great discomfort and at certain times there appears to have been insufficient cooling and heating. Some children in separation detention appear to have had insufficient access to open air. The provision of shoes was at times inadequate for the needs of children in the remote desert surroundings. The detention facilities were filled beyond capacity for months at a time, resulting in overcrowding. There were also insufficient systems in place to ensure that the toilets and accommodation blocks were clean.

The Inquiry also finds that food was not tailored to the needs of children, and was variable in quality over the period of the Inquiry. Moreover, there is no evidence that individual nutritional assessments of children were conducted over the period of time covered by the Inquiry, in order to ensure that any pre-existing nutritional deficiencies were being addressed. The provision of baby formula and special food for infants was uneven.

As the Bollen Report notes, the policies and practices for the provision of health services to detention facilities were unclear in several areas and differed between centres. The inevitable result was that the quality of health care provided to children varied over the period of time covered by this Inquiry, with most improvements occurring after the Bollen Report was delivered to the Department at the end of 2001.

The health assessment procedures sometimes failed to identify illnesses that were identified shortly after release from detention. The evidence suggests a lack of comprehensive initial health assessments addressing the special vulnerabilities of children seeking asylum. There were no requirements that health care staff have the necessary expertise to diagnose and treat illnesses of child asylum seekers, including expertise in paediatrics and refugee health. Further, while it appears that the Department and ACM made some efforts to provide cross-cultural training, the specific content and effectiveness of that training remain unclear. Furthermore, there was a shortage of on-site interpreters for the purpose of medical examinations, especially in Port Hedland. On-site interpreters are especially important for the examination of asylum-seeking children.

The number of on-site health staff was insufficient to fully meet the needs of the detainee population at various times. The system of triage led to delays in accessing doctors. There were also delays in children receiving their medication.

The absence of clear procedures for referring detainees in remote areas to external doctors and hospitals, and the difficulties associated with isolation in these remote areas, were frustrating for doctors and led to delays in external treatment. The Bollen Report notes that the level of secondary care available to detainees in remote centres at the end of 2001 was less than the standard available to the Australian community. The evidence before the Inquiry does not establish that cost was a barrier to accessing external services, although one doctor perceived this to be the case.

The location of the detention facilities, coupled with lack of access to interpreters, also made the birthing arrangements for pregnant women in detention less than ideal. Further, while the Department and ACM facilitated contact between parents and children when a member of the family was hospitalised, the frequency of contact appears to have been restricted by the detention environment.

The dental care provided to children was inadequate for the needs of long-term detainee children. The system for providing medical records to detainees on release appears to have been wanting. However, it seems that newborn infants were appropriately immunised and that immunisations were given to older children at certain points in time.

Together these factors lead the Inquiry to find that the Commonwealth breached articles 24(1) and 39 of the CRC.

The Inquiry also finds that the above shortcomings in the provision of health care reflects an inadequate acknowledgement of the special needs of asylum-seeking children and a corresponding failure to take appropriate measures to ensure that they received appropriate protection in the enjoyment of their rights to the highest standard of health under the CRC. This breaches article 22(1).

As suggested earlier, the Inquiry acknowledges that the circumstances in remote detention facilities created hurdles for staff who were trying to provide appropriate health care services. For example, the desert climate had an impact on the ailments that children suffered in detention. The remote location had a negative impact on the ability to recruit sufficient numbers of appropriately qualified refugee and paediatric health care workers, interpreters and dentists. Detention in remote areas also inhibited access to appropriate secondary care (including specialists and hospitals) and created tensions regarding the preservation of family unity during hospitalisation, especially during births.

Concerns peculiar to the detention environment also created barriers for staff. For instance, whereas full courses of medication are usually provided to parents in the community, children in detention had to line up for each dose for fear that they may use the medication inappropriately. Such impediments to the provision of adequate levels of health care may indicate that the best interests of the child were not a primary consideration for the Department in its decisions regarding the location of children, contrary to article 3(1). This is considered further in Chapter 17.

Infrastructure limitations also had an impact. The Inquiry acknowledges that influxes of arrivals sometimes placed a great deal of strain on the facilities. Such influxes led both to overcrowding and increased demand on health services. However, unpredictable numbers of arrivals are inherent to the nature of immigration detention and require appropriate contingency planning. The Inquiry notes that if the numbers of people in detention become so great as to threaten the health care services available to children in detention, options such as releasing or transferring families to alternative places of detention may be the appropriate course of action, rather than detention in circumstances in which their basic rights cannot be met.

The Inquiry notes that decisions as to the location and manner of detention are within the control of the Department and the failure to consider and implement alternatives to detention when there were overcrowded remote centres suggests that the interests of children were not a primary consideration for the Department when it made such decisions. The Inquiry acknowledges that this problem was exacerbated by inadequate flexibility in the detention laws to deal with such contingencies. This reinforces the Inquiry's concern that Australia's detention laws, and the manner in which they are applied, fail to adequately consider the best interests of the child (article 3(1)). This issue is considered further in Chapter 17.

Finally, it is clear that the longer children are in detention the greater their needs. For example, while access to preventative dental care may not be important if children are in detention for short periods, it is vital if children are detained for long periods

- especially when many children seeking asylum start out with dental healthproblems. Similarly, the monotony of a menu or the absence of individualised nutritional assessments may not create great problems in the short term but can have a great impact on children in the long term.

The Inquiry finds that, to a certain extent, the long-term detention of children in remote facilities inevitably results in an unhealthy environment for physical and psychological recovery and leads to a lower standard of health than these children might achieve if they were living in the Australian community. This further reinforces the Inquiry's concern that the mandatory detention laws, and the manner in which they are applied by the Minister and the Department, fail to take into account the best interests of the child as required by article 3(1) of the CRC. It also highlights the connection between the need to be detained as a matter of last resort and for the shortest appropriate period of time, and the ability to enjoy the right to the highest attainable standard of health.

The conditions of detention and the processes in place to provide health care services are also factors to take into account when considering whether there has been a breach of a child's right to the maximum possible development (article 6(2)) and the right to be treated with humanity and respect for the inherent dignity of the human person (article 37(c)). Compliance with the JDL Rules is a useful guide in determining whether children in detention have been treated in accordance with article 37(c). The Inquiry notes that those rules suggest, amongst other things, that there should be immediate access to adequate medical facilities and equipment appropriate to the numbers and requirements of its residents and that, ideally, treatment should occur in health facilities in the community. Also there should be adequate preventative and remedial dental and ophthalmological care. As set out above, these rules have not been complied with at certain points in time. However, the Inquiry's findings regarding articles 6(2) and 37(c) are addressed more generally in Chapter 17.

Endnotes

1. Paul Hunt, Special Rapporteur on the right to the enjoyment of the highest attainable standard of physical and mental health, 'Healthy Environments for Children', 7 April 2003.
2. General Comment 14 of the Committee for Economic Social and Cultural Rights which outlines the core obligations under article 12 of the ICESR. See also HREOC, National Inquiry into Children in Immigration Detention, Background Paper No.4, Health and Nutrition, p3.
3. Article 37(c) mirrors article 10(1) of the International Covenant on Civil and Political Rights (ICCPR). The Human Rights and Equal Opportunity Commission (the Commission) has previously found that failure to provide medical treatment to a detainee in immigration detention resulted in a breach of this article 10(1) of the ICCPR: HREOC, Report of an inquiry into a complaint by Mr Hassan Ghomwari concerning his immigration detention and the adequacy of the medical treatment he received while detained, HREOC Report No. 23, October 2002. The UN Human Rights Committee has encouraged State Parties to report on whether they are applying UN guidelines on the treatment of prisoners in order to assist it in assessing whether or not there has been a breach of article 10. See Human Rights Committee, General Comment 21, para 5.
4. See also Save the Children and UNHCR, Separated Children in Europe Programme, Statement of Good Practice, 2000, para 10.
5. Committee on the Elimination of Discrimination Against Women, General Recommendation 24, 1999, para 6.
6. DIMIA, Submission 185, p56. See also DIMIA Managers' Handbook, Section 5.1, Issue 3, 30 April 2002, para 2.
7. IDS, 1998, section 8.1, www.immi.gov.au/detention/det_standards.htm.
8. See further Chapter 8 on Safety and Chapter 9 on Mental Health for further discussion of the operation of State child welfare legislation in immigration detention centres.
9. See Melbourne International Health and Justice Group, Submission 63, p15. The Department informed the Inquiry that it does not automatically apply juvenile justice standards as they relate to punitive rather than administrative detention: DIMIA, Response to Draft Report, 10 July 2003.
10. DIMIA Managers' Handbook, Section 5.1, Issue 3, 30 April 2002, para 3. See also DIMIA, Submission 185, p3.
11. DIMIA, Submission 185, p57, Appendix C p133.
12. IDS, 1998, sections 8.2-8.4; DIMIA Managers' Handbook, Section 5.1, Issue 3, 30 April 2002, paras 6, 11.
13. IDS, 1998, sections 9.2, 9.3.
14. DIMIA Managers' Handbook, Section 4.3, Issue 1, 21 December 2001; IDS, 1998, section 9.5.
15. DIMIA Managers' Handbook, Section 5.1, Issue 3, 30 April 2002, para 9.
16. DIMIA Managers' Handbook, Section 5.1, Issue 3, 30 April 2002, para 10.
17. ACM states that it monitors the physical health of all children through Individual Management Plans, amongst other mechanisms. ACM, Response to Draft Report, 22 August 2003. The quality of these plans is discussed in relation to unaccompanied children in Chapter 14 on Unaccompanied Children.
18. DIMIA, Response to Draft Report, 10 July 2003.
19. DHS, Submission 181, p43.
20. Dr Michael Bollen and Dr Chris Bollen, Review of Health Services at Immigration Detention Centres and Immigration Reception and Processing Centres, October-November 2001 (Bollen Report) (N1, Q9, F10).
21. ACM, The Bollen Report - Status of Recommendations: Update on Matters Raised in the Report, 11 June 2002; DIMIA Assistant Secretary, Memo, to Minister, 28 March 2002, (N1, Q9, F10).
22. DIMIA Managers' Handbook, Section 5.1, Issue 3, 30 April 2002, para 7.
23. DIMIA, Response to Information Required, (N4, Q9, F8).
24. Under new contract arrangements with Group 4 Falck, the requirements outlined in the Handbook, as described above, will apply in all facilities. DIMIA, Response to Draft Report, 10 July 2003.
25. Bollen Report, p47. (N1, Q9, F10).
26. DIMIA, Response to Draft Report, 10 July 2003.
27. Inquiry, Notes from visit, Port Hedland, June 2002.
28. DIMIA Managers' Handbook, Section 5.1, Issue 3, 30 April 2002, para 7.
29. DIMIA, Submission 185, p57.
30. ACM Health Services Operating Manual, Policy 6.13, Detainees Immunisation, Issue 2, 9 May 2002, (N1, Q8, F9).
31. ACM, Policy 9.2, Detainee Menus, Issue 4, 12 August 2001, para 4.8.
32. ACM Health Services Operating Manual, Policy 10.0, Female Detainees - Health Care, Issue 2, 9 May 2002, (N1, Q8, F9).
33. ACM Health Services Operating Manual, Policy 10.1, Female Detainees - Pregnancy, Issue 2, 9 May 2002, (N1, Q8, F9); ACM Health Services Operating Manual, Policy 10.2, Pregnant Detainees, Issue 2, 9 May 2002, (N1, Q8, F9). See also ACM, Policy 16.3, Special Care Needs for Pregnant Women, Issue 4, 12 August 2001, (N1, Q1, F2).
34. ACM Woomera, Procedure 8.01, Hygiene, 16 November 2001, (N1, Q8, F9).
35. ACM Woomera, Procedure 9.03, Food Services Hygiene, 16 November 2001, (N1, Q8, F9).
36. ACM Woomera Residential Housing Project, Procedure 26.03, Medical Policy, 16 November 2001, (N1, Q8, F9).
37. ACM Woomera, Procedure 6.01, Health Services Policy and Procedures Manual, 16 November 2001, (N1, Q8, F9).
38. ACM, The Bollen Report - Status of Recommendations: Update on Matters Raised in the Report, 11 June 2002, (N1, Q9, F10).
39. Executive Director Medical, Letter, to Director of Medical Services, North West Health Services, (N4, Q9, F8).
40. DIMIA, Submission 185, p58.
41. DIMIA, Response to Draft Report, 10 July 2003, ACM, Response to Draft Report, 22 August 2003.
42. Dr Annie Sparrow, Transcript of Evidence, Perth, 10 June 2002, p63. Dr Sparrow was employed at Woomera only.
43. DIMIA, Transcript of Evidence, 2 December 2002, p6.
44. Bollen Report, p8, (N1, Q9, F10).
45. Kids in Detention Story, Submission 196, Health Section, pp19-20.
46. DIMIA, Submission 185, pp72-73. See also ACM, Response to Draft Report, 22 August 2003.
47. Melbourne International Health and Justice Group, Submission 63, p55.
48. Bollen Report, Recommendation 32, p66, (N1, Q9, F10).
49. S MacQueen, Review of the Food Service and Menu at the Woomera Immigration Reception and Processing Centre (WIRPC) with Particular Reference to the Nutritional Needs of Young Children, 31 May 2002, (N1, Q8, F9). The same recommendations were made in respect to a review of the food and menu at Villawood detention centre: Sally MacQueen, Review of the Food Service and Menu at the Villawood Immigration Detention Centre (VIDC), with Particular Reference to the Nutritional Needs of Young Children, 21 June 2002.ACM, Response to Draft Report, 22 August 2003. ACM states that a nutritionist 'continues to review and advise on all detention centre menus at least annually': ACM, Response to Draft Report, 22 August 2003.
50. ACM, Response to Draft Report, 22 August 2003.
51. S MacQueen, Review of the Food Service and Menu at the Woomera Immigration Reception and Processing Centre (WIRPC) with Particular Reference to the Nutritional Needs of Young Children, 31 May 2002, (N1, Q8, F9). See also Bollen Report, pp64-65 (N1, Q9, F10).
52. Dr Annie Sparrow, Transcript of Evidence, Perth 10 June 2002, p73.
53. S MacQueen, Review of the Food Service and Menu at the Woomera Immigration Reception and Processing Centre (WIRPC) with Particular Reference to the Nutritional Needs of Young Children, 31 May 2002, (N1, Q8, F9).
54. Allan Clifton, Transcript of Evidence, Adelaide, 2 July 2002, p7. Mr Clifton was the former Operations Manager at Woomera from early 2000 until July 2001. He also worked as Centre Manager at Perth and spent a few weeks at Christmas Island facility following his time at Woomera.
55. Allan Clifton, Transcript of Evidence, Adelaide, 2 July 2002, p8.
56. ACM, Response to Draft Report, 22 August 2003.
57. ACM, Letter to Inquiry, 14 January 2003.
58. ACM, Detention Services Monthly Report, Curtin, December 2001, p126.
59. ACM, Letter to Inquiry, 14 January 2003.
60. DIMIA Port Hedland, Manager Report, January-March 2001, (N1, Q3a, F5).
61. DIMIA Curtin, Manager Reports, November 2001, December 2001, April 2002, May 2002, (N1, Q3a, F5).
62. DIMIA, Contract Operation Group Minutes, 20 June 2002, (N1, Q3, F4).
63. ACM, Response to Draft Report, 22 August 2003.
64. ACM, Detention Services Monthly Report, April 2001, Services and Assets End of Month Report, (p60).
65. Inquiry, Notes from visit, Baxter, December 2002.
66. Performance Linked Fee Report for quarter ending 30 September 2001, 18 December 2001, p12.
67. Inquiry, Focus group, Sydney, March 2002; Inquiry, Focus group with Iraqi boys, Melbourne, 30 May 2002.
68. Focus group with Afghan and Iraqi unaccompanied boys, Melbourne, May 2002.
69. ACM Managing Director, Letter, Comments on Performance Assessment for the Quarter Ending September 2001, to DIMIA First Assistant Secretary, 4 February 2002, Attachment para 8.4.
70. Confidential Transcript of Evidence, Adelaide, 1 July 2002, p20.
71. Inquiry, Interview with detainees, Woomera, June 2002.
72. DIMIA, Response to Draft Report, 10 July 2003. Some menus were also obtained during visits to detention centres.
73. DIMIA Curtin, Manager Report, May 2002, (N1, Q3a, F5).
74. National Legal Aid, Submission 171, p22.
75. Inquiry, Focus group, with Afghan teenage boys and girls, Perth, June 2002.
76. Inquiry, Focus group with teenage unaccompanied children, all ex-Curtin, Perth, June 2002.
77. Curtin DIMIA, Manager Report, May 2002, (N1, Q3a, F5).
78. Most centres hold regular detainee representative meetings where detainees can raise issues of concern with centre management. Children do not generally participate in the meetings.
79. ACM, Policy 9.2, Detainee Menus, Issue 4, 12 August 2001, para 4.8.
80. ACM, Letter to Inquiry, 14 January 2003.
81. DIMIA, Response to Draft Report, 10 July 2003.
82. ACM, Response to Draft Report, 22 August 2003.
83. Australian Association for Infant Mental Health (AAIMH), Transcript of Evidence, Adelaide, 1 July 2002, p31. See also Melbourne International Health and Justice Group, Transcript of Evidence, 31 May 2002, p41.
84. ACM, Response to Draft Report, 22 August 2003.
85. Inquiry, Focus group with Iraqi primary school children and their parents, Perth, June 2002.
86. Inquiry, Focus group with Afghan teenage boys and girls, Perth, June 2002. See also Kids in Detention Story, Submission 196, Health Section, p33.
87. Dr Annie Sparrow, Transcript of Evidence, Perth, 10 June 2002, p73.
88. Barbara Rogalla, Transcript of Evidence, Melbourne, 30 May 2002, p34.
89. Mark Huxtep, Submission 248a, paras 31-34.
90. Confidential Submission 255, p7.
91. Inquiry, Interview with detainees, Woomera, June 2002.
92. DIMIA, Submission 185, p74; ACM, Letter to Inquiry, 14 January 2003.
93. Confidential Transcript of Evidence, Adelaide, 1 July 2002, p27.
94. Allan Clifton, Transcript of Evidence, Adelaide, 2 July 2002, p21.
95. Dr Bernice Pfitzner, Transcript of Evidence, Sydney, 16 July 2002, p4.
96. ACM, Response to Draft Report, 22 August 2003.
97. Confidential, Transcript of Evidence, Adelaide, 2 July 2002, p81.
98. DHS, Woomera Detention Centre Assessment Report, 12 April 2002, Submission 181a, p11.
99. Confidential, Transcript of Evidence, Adelaide, 2 July 2002, p78.
100. Confidential, Transcript of Evidence, Adelaide, 2 July 2002, p80.
101. Mark Huxtep, Submission 248a, paras 15-16.
102. DIMIA, Response to Draft Report, 10 July 2003.
103. DIMIA, Transcript of Evidence, Sydney, 5 December 2002, p98.
104. Inquiry, Focus Group, Adelaide, July 2002. See also Alliance of Health Professionals, Submission 109, p26.
105. DIMIA Port Hedland, Manager Report, February 2002, (N1, Q3a, F5).
106. Inquiry, Focus Group, Brisbane, August 2002.
107. ACM, Response to Draft Report, 22 August 2003.
108. Inquiry, Interview with family, Curtin, June 2002. Inquiry, Interview with family, Baxter, December 2002.
109. Confidential, Transcript of Evidence, Perth, 10 June 2002, p18.
110. Dr Paul Carroll, Transcript of Evidence, Perth, 10 June 2002, p62.
111. National Legal Aid, Submission 171, p22.
112. Inquiry, Focus groups with teenage boys, Perth, June 2002 and Melbourne, May 2002.
113. Inquiry, Focus group with unaccompanied children, all ex-Curtin, Perth, June 2002.
114. Inquiry, Focus group with unaccompanied children, all ex-Curtin, Perth, June 2002.
115. Inquiry, Interview with detainees, Woomera June 2002.
116. Inquiry, Focus group with Iraqi primary school children, Perth, June 2002.
117. See further Chapter 7 on Refugee Status Determination, which discusses separation detention as a Departmental requirement for new arrivals.
118. Inquiry, Interview with former Port Hedland detainee family, Melbourne, May 2002.
119. Inquiry, Interview with detainees, Port Hedland, June 2002.
120. Alliance of Health Professionals, Submission 109, p21.
121. IDS, 1998, para 8.2.1.
122. In 2000 in Woomera the amount of donated clothing from Sabian Mandaeans was so great that there were substantial delays in distributing the clothing. See Performance Linked Fee Report for quarter ending 30 September 2000, 23 March 2001, para 8.2. In May 2001 ACM notes that it has rectified the problem. ACM Managing Director, Letter, to DIMIA First Assistant Secretary, 8 May 2001.
123. CARAD, Transcript of Evidence, Perth, 10 June 2002, p28.
124. Inquiry, Focus group with Afghan teenage boys and girls, Perth, June 2002.
125. DIMIA Port Hedland, Manager Report, October 2001, (N1, Q3a, F5).
126. DIMIA Port Hedland, Manager Report, January 2002, (N1, Q3a, F5).
127. DIMIA Port Hedland, Manager Report, February 2002, (N1, Q3a, F5).
128. Barbara Rogalla, Transcript of Evidence, Melbourne, 30 May 2002, p34.
129. The Department states that on occasions it has purchased additional footwear for young detainees, for example for external school excursions: DIMIA, Response to Draft Report, 10 July 2003.
130. For example, Youth Advocacy Centre and Queensland Program of Assistance to Survivors of Torture and Trauma, Submission 84, p9. Also, DIMIA Woomera, Manager Report, March 2000, (N1, Q4a, Attachment A) noted that privacy within the compound for women and children is severely hampered by the overcrowding of accommodation constraints. Crowded sleeping accommodation was also raised with the Human Rights Commissioner during his visits to detention centres in 2001: HREOC, A report on visits to immigration detention facilities by the Human Rights Commissioner 2001, p32.
131. DIMIA, Letter to Inquiry, 24 December 2002, Attachment F.
132. Inquiry, Interview with detainees, Curtin, June 2002.
133. See for example, Kids in Detention Story, Submission 196, Health Section, p23; Mental Health Section p16, Further Interview Material, Appendix 1.
134. Inquiry, Notes from visit, Woomera, June 2002.
135. DHS, Woomera Detention Centre Assessment Report, 12 April 2002, Submission 181a, p11.
136. ACM Woomera, Medical Records, 2 September 2001, Perrett Medical Imaging, X-Ray Report, 7 September 2001; ACM Woomera, Medical Incident Report, 5 September 2001, (N5, Case 17, pp6, 22, 40).
137. Former Department Infrastructure Manager Woomera 2000, Transcript of Evidence, Adelaide, 1 July 2002, p9.
138. ACM, Response to Draft Report, 22 August 2003.
139. Performance Linked Fee Report, for quarter ending 30 June 2000, paras 7.7, 8.5.
140. DIMIA Woomera, Manager Report, January-March 2001, (N1, Q4a, F5).
141. National Legal Aid, Submission 171, p22.
142. ACM, Response to Draft Report, 22 August 2003.
143. DIMIA Port Hedland, Manager Report, February 2002, (N1, Q3a, F5).
144. DIMIA Port Hedland, Manager Report, March 2002, (N1, Q3a, F5).
145. DIMIA, Response to Draft Report, 10 July 2003.
146. Bollen Report, Recommendation 34, p105 (N1, Q9, F10). DIMIA Assistant Secretary, Memo, to Minister, 28 March 2002, (N1, Q9, F10); ACM, The Bollen Report - Status of Recommendations: Update on Matters Raised in the Report, 11 June 2002, (N1, F10, Q9).
147. In addition, within the first two weeks of detention a further medical assessment is conducted as part of the visa application process by Health Services Australia (HAS), which comprises a physical examination and questionnaire. DIMIA, Submission 185, p59.
148. DIMIA, Submission 185, Appendix E, pp143-145.
149. Melbourne International Health and Justice Group, Transcript of Evidence, Melbourne, 31 May 2002, p35. See also Plan of Action for Implementing the World Declaration on the Survival, Protection and Development of Children in the 1990s, United Nations Children's Fund, 1990. Screening tests are routinely performed, for example, on all babies born in New South Wales (where parental consent is obtained). NSW Department of Health, Newborn screening: Test to protect your baby, 1998.
150. Bollen Report, p51, (N1, Q9, F10).
151. ACM Curtin Acting Health Services Coordinator, Letter, Re: Statistics on Children in Detention, to ACM National Operations Manager, 1 February 2002, (N1, Q8, F9).
152. DIMIA, Response to Draft Report, 10 July 2003.
153. ACM, Response to Draft Report, 22 August 2003.
154. NSW Commission for Children and Young People, Submission 258, pp36-38. See also, for example, HREOC, Those who've come across the seas, 1998, pp165-167.
155. NSW Commission for Children and Young People, Submission 258, p37-38.
156. NSW Commission for Children and Young People, Submission 258, p36.
157. SA Coalition for Refugee Children, Submission 183, p16. See also NSW Commissioner for Children, Submission 258, pp37-38.
158. ACM, Response to Draft Report, 22 August 2003.
159. DIMIA, Submission 185, p58.
160. Bollen Report, p32, (N1, Q9, F10).
161. DIMIA, Submission 185, p58.
162. Bollen Report, p33, (N1, Q9, F10).
163. Bollen Report, p36, (N1, Q9, F10).
164. Dr Annie Sparrow, Transcript of Evidence, Perth, 10 June 2002.
165. Barbara Rogalla, Transcript of Evidence, Melbourne, 30 May 2002, pp35-36.
166. DIMIA, Response to Draft Report, 10 July 2003. ACM has also pointed out that only a small percentage of children and babies in the community receive screening by paediatricians: ACM, Response to Draft Report, 22 August 2003.
167. Bollen Report, p46, (N1, Q9, F10).
168. ACM, The Bollen Report - Status of Recommendations: Update on Matters Raised in the Report, 11 June 2002, (N1, F10, Q9).
169. D Silove, Z Steel, C Watters, 'Policies of Deterrence and the mental health of asylum seekers in Western countries', Journal of the Australian Medical Association, vol 284, 2000, p605.
170. DIMIA, Response to Draft Report, 10 July 2003.
171. ACM, Response to Draft Report, 22 August 2003.
172. Inquiry, Notes from visit, Woomera, June 2002. See also Donna Bradshaw, Email to Inquiry, 2 October 2002.
173. Dr Bernice Pfitzner, Transcript of Evidence, Sydney, 16 July 2002, p12.
174. DIMIA, Response to Draft Report, 10 July 2003.
175. Bollen Report, Recommendation 5, p34-35, (N1, Q9, F10).
176. ACM, The Bollen Report - Status of Recommendations: Update on Matters Raised in the Report, 11 June 2002, (N1, Q9, F10). See also DIMIA Assistant Secretary, Memo, to Minister, 28 March 2002, (N1, Q9, F10). Other reference material that may be useful includes the guidelines on refugee health prepared by countries like the UK and New Zealand: New Zealand, Ministry of Health, Refugee Health Care: A Handbook for Health Professionals, Auckland, 2001; British Medical Association, Asylum-seekers: meeting their health care needs, October 2002. Also, Victorian Foundation for Survivors of Torture, Caring for Refugee Patients in General Practice - A Desk-top Guide 2nd Edition, 2002.
177. Adult detainees have complained previously to the Commission about the lack of use of interpreters. See, for example, HREOC, A report on visits to immigration detention facilities by the Human Rights Commissioner 2001, p36; HREOC, Immigration Detention, Human Rights Commissioner's 1998- 99 Review, pp29-30.
178. DIMIA Port Hedland, Manager Reports, January-March 2001, July-September 2001, November 2001, December 2001, January 2002, February 2002, March 2002, April 2002, June 2002, (N1, Q3a&4a, F5).
179. ACM, Response to Draft Report, 22 August 2003.
180. DIMIA, Transcript of Evidence, Sydney, 2 December 2002, pp71-79. It has also been noted in the Performance Linked Fee Reports, which assess the performance of ACM, since at least June 2000: Performance Linked Fee Report, for quarter ending 30 June 2000, 19 December 2000, para 3.
181. DIMIA, Transcript of Evidence, Sydney, 2 December 2002, p77.
182. DIMIA Port Hedland, Manager Report, September 2002, (N4, Q1, F1).
183. ACM, Response to Draft Report, 22 August 2003.
184. DIMIA, Transcript of Evidence, Sydney, 2 December 2002, p71.
185. See for example, DIMIA, Transcript of Evidence, Sydney, 2 December 2002, p74. ACM has, however, provided the Inquiry with the number of times TIS was used by all staff at all centres during 2002/ 2003, which appears to indicate extensive usage. For example, between July and December 2002, TIS was used 235 times and on-site interpreters were used only 34 times: ACM, Response to Draft Report, 22 August 2003.
186. Bollen Report, p63, (N1, Q9, F10).
187. Inquiry, Notes from visit, Curtin, June 2002. TIS can provide female interpreters on request, although access may not be immediate.
188. DIMIA, Response to Draft Report, 10 July 2003.
189. Dr Paul Carroll, Transcript of Evidence, Perth, 10 June 2002, p74.
190. Dr Paul Carroll, Transcript of Evidence, Perth, 10 June 2002, p75.
191. DIMIA, Submission 185, Appendix D, pp135-141.
192. DIMIA, Submission 185, Appendix D, pp135-141.
193. DIMIA, Submission 185, Appendix C, p133.
194. Complaints of poor access to health staff by adult detainees have been made occasionally to the Commission over the past several years. See HREOC, A Report on Visits to Immigration Detention Facilities by the Human Rights Commissioner 2001, p35. Also, a HREOC inquiry into a complaint found that a detainee with Hepatitis B was not provided with adequate medical treatment at Villawood in June 2000, in part because of the absence of a medical officer on a daily basis. HREOC, Report of an inquiry into a complaint by Mr Hassan Ghomwari concerning his immigration detention and the adequacy of the medical treatment he received while detained, HREOC Report No.23, August 2002.
195. Bollen Report, p31, (N1, Q9, F10).
196. Dr Bernice Pfitzner, Transcript of Evidence, Sydney, 16 July 2002, p13.
197. Inquiry, Notes from visit, Woomera, June 2002.
198. DIMIA Port Hedland, Manager Report, January-March 2001, (N1, Q4a, F5).
199. Bollen Report, pp39-40, (N1, Q9, F10).
200. Department of Human Services Victoria, Submission 200, p13.
201. Dr Paul Carroll, Transcript of Evidence, Perth, 10 June 2002, p75. The practice of referring to a detainee by number, and its impact on children, is discussed in section 9.3.7 in Chapter 9 on Mental Health. ACM states that it is 'important to recognise that recording a detainee's number is a critical and important way of ensuring the correct identity for the purpose of treatment and medication' ACM, Response to Draft Report, 22 August 2003. However, recording the number is different from calling the number out over the loudspeaker.
202. Barbara Rogalla, Transcript of Evidence, Melbourne, 30 May 2002, p37.
203. Dr Bernice Pfitzner, Transcript of Evidence, Sydney, 16 July 2002, pp10-11.
204. Inquiry, Focus Group, with Afghan unaccompanied boys, Adelaide, July 2002.
205. Bollen Report, p52, (N1, Q9, F10).
206. ACM, The Bollen Report - Status of Recommendations: Update on Matters Raised in the Report, 11 June 2002, (N1, Q9, F10).
207. Mark Huxtep, Submission 248a, para 14.
208. National Legal Aid, Submission 171, p22.
209. DIMIA, Submission 185, p61.
210. Mark Huxtep, Submission 248a, paras 11-12.
211. Focus group, with Afghan unaccompanied boys, Adelaide, July 2002.
212. Focus group, Melbourne, May 2002.
213. DIMIA, Submission 185, p57.
214. Bollen Report, p47, (N1, Q9, F10).
215. Bollen Report, p13, (N1, Q9, F10).
216. DIMIA, Response to Draft Report, 10 July 2003.
217. Medical Adviser, Health Services Australia, Report to Doctor in Charge, Curtin Detention Centre, 26 May 2001, (N5, Case 5, p18).
218. ACM Curtin, Medical Records, 25 June 2001, 29 June 2001, (N5, Case 5, pp7-8).
219. Inquiry, Interview with unaccompanied child, Adelaide, July 2002.
220. Department of Human Services Victoria, Submission 200, p13.
221. DIMIA Curtin, Manager Report, March 2002, (N1, Q3a, F5).
222. NSW Commissioner for Children and Young People, Submission 258, p37.
223. Dr Bernice Pftzner, Transcript of Evidence, Sydney, 16 July 2002, pp13-14. See also Dr Paul Carroll, Transcript of Evidence, Perth 10 June 2002, p69.
224. Dr Paul Carroll, Transcript of Evidence, Perth, 10 June 2002, p69.
225. ACM, Response to Draft Report, 22 August 2003.
226. Dr Paul Carroll, Transcript of Evidence, Perth, 10 June 2002, p69.
227. Western Australian Government, Transcript of Evidence, Perth 10 June 2002, p43.
228. Dr Bernice Pfitzner, Submission 264, para 16. Inquiry, Notes from visit, Curtin, June 2002.
229. ACM, Response to Draft Report, 22 August 2003.
230. Dr Bernice Pftzner, Transcript of Evidence, Sydney, 16 July 2002, p11.
231. ACM, The Bollen Report - Status of Recommendations: Update on Matters Raised in the Report, 11 June 2002, (N1, Q9, F10).
232. The circumstances are that the parent stays in a motel under 24-hour ACM guard and the child is in hospital alone but with an ACM guard in the room with them 24 hours a day.
233. Inquiry, Interview with refugee family, Melbourne, May 2002.
234. Confidential Submission 203, p13.
235. DIMIA, Response to Draft Report, 10 July 2003.
236. This case is also discussed in section 14.6.2 in Chapter 14 on Unaccompanied Children.
237. The Inquiry is aware of two exceptions: A two-year-old was permitted to stay at Woomera Hospital with his mother and a baby was permitted to stay at a Sydney hospital with her mother for a longer time.
238. ACM Woomera, Medical Records, 3 June 2002, (N3, F12).
239. ACM Woomera, Medical Records, 4 June 2002, (N3, F12).
240. ACM, Response to Draft Report, 5 September 2003.
241. ACM Woomera, HRAT Watch Log, 30 June 2002, (N3, F9).
242. ACM Woomera, HRAT Watch Log, 6 July 2002, (N3, F9). Two other children from different families told the Inquiry that the only way they could get ACM to take them to see their mothers in hospital more often was to climb up above the razor wire and threaten to jump, (Inquiry, Interviews with detainees, Woomera, June and September, 2002). However, due to the confidentiality of these allegations, ACM did not have the opportunity to verify whether this was the case.
243. ACM Woomera, HRAT Watch Log, 31 May 2002, (N3, F9).
244. DIMIA, Response to Second Draft Report, 27 January 2004. See further Chapter 3, Setting the Scene, section 3.5.3.
245. AAIMH, Submission 29, pp5-6.
246. DHS, Woomera Detention Centre Assessment Report, 12 April 2002, Submission 181a, pp19-20.
247. Minister for Immigration and Multicultural and Indigenous Affairs, Pregnant Women in Detention, HREOC Children in Detention Inquiry 2002 Public Hearings - fact versus fiction, www.minister.immi. gov.au/borders/detention/hreoc_issues/women.htm, viewed 15 December 2003.
248. See also DIMIA, Response to Draft Report, 10 July 2003.
249. ACM, Response to Draft Report, 22 August 2003.
250. AAIMH, Transcript of Evidence, Adelaide, 1 July 2002, p28.
251. Bollen Report, pp46-47, (N1, Q9, F10).
252. Dr Bernice Pftzner, Transcript of Evidence, Sydney, 16 July 2002, p3.
253. DIMIA Woomera, Manager Report, January-March 2000. (N1, Q4a, Attachment A).
254. DIMIA, Submission 185, p68.
255. DHS, Woomera Detention Centre Assessment Report, 12 April 2002, Submission 181a, p19.
256. DIMIA Woomera, Manager Report, September 2002, (N4, Q1, F1).
257. Michael Hall, Submission 288, p4.
258. ACM, Response to Draft Report, 5 September 2003.
259. DIMIA, Submission 185, p61.
260. Bollen Report, p49, (N1, Q9, F10).
261. Bollen Report, p49, (N1, Q9, F10).
262. Bollen Report, p50, (N1, Q9, F10).
263. Inquiry, Focus group, Melbourne, May 2002.
264. ACM Detention Services Monthly Report, Health Services Monthly Report, December 2001, p72.
265. ACM Detention Services Monthly Report, Woomera, May 2002, p158.
266. ACM, The Bollen Report - Status of Recommendations: Update on Matters Raised in the Report, 11 June 2002, (N1, Q9, F10).
267. DIMIA Curtin, Manager Report, July 2002, (N4, Q1, F1).
268. ACM, Response to Draft Report, 22 August 2003.
269. DIMIA Curtin, Manager Report, August 2002, (N4, F1, Q1).
270. Inquiry, Notes from visit, Baxter, December 2002.
271. Bollen Report, p50, (N1, Q9, F10).
272. DIMIA, Submission 185, p63. However, ACM also states that it does not have total control over the process of recording immunisation as 'records of immunisation are not able to be provided where release occurs without notification to ACM': ACM, Response to Draft Report, 22 August 2003.
273. Bollen Report, pp45-46, (N1, Q9, F10). See also, Ms Karyn Fromene, Adelaide Northern Division of General Practice, Transcript of Evidence, Adelaide, 1 July 2002, pp10-12.
274. Dr Bernice Pfitzner, Submission 264, para 20. See also Dr Bernice Pftzner, Transcript of Evidence, Sydney, 16 July 2002, pp11-12.
275. ACM, Detention Services Monthly Report, Health Care Report, June 2001, p43.
276. ACM, Detention Services Monthly Report, Health Care Report, September 2001, p67.
277. Karyn Fromene, Transcript of Evidence, Adelaide, 1 July 2002, p9.
278. Karyn Fromene, Transcript of Evidence, Adelaide, 1 July 2002, p12.
279. Angela Newbound, Transcript of Evidence, Adelaide, 1 July 2002, p38.
280. DIMIA, Contract Operations Group Minutes, 23 May 2002, (N1, Q3, F4).
281. DIMIA, Contract Operations Group Minutes, 20 June 2002, (N1, Q3, F4).
282. ACM, Detention Services Monthly Report, Woomera, July 2002, p166.
283. Angela Newbound, Transcript of Evidence, Adelaide, 1 July 2002, p34.
284. ACM, Detention Services Monthly Report, Health Services Monthly Report, August 2002, p76.
285. ACM, Detention Services Monthly Report, Curtin, February 2001, p79. ACM, Detention Services Monthly Report, Health Care Report, December 2001, p73.
286. ACM, Response to Draft Report, 22 August 2003.
287. Karyn Fromene, Transcript of Evidence, Adelaide, 1 July 2002, p13.
288. DIMIA, Response to Draft Report, 10 July 2003.
289. Angela Newbound, Transcript of Evidence, Adelaide, 1 July 2002, p35.
290. Karyn Fromene, Transcript of Evidence, Adelaide, 1 July 2002, p10.
291. DHS, Submission 181, p26.
292. Department of Human Services Victoria, Submission 200, p13.
293. DIMIA, Response to Draft Report, 10 July 2003.
294. ACM, Response to Draft Report, 22 August 2003.

13 May 2004