FOR OFFICIAL USE ONLY - SENSITIVE REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING TO THE MENTAL HEALTH OF DETAINEES PARTICULARLY CHILDREN. Author: Stephen Wood Assistant Secretary Professional Integrity and Assurance Branch Department of Immigration and Border Protection Date: 04 September 2014 Version: Final 1.0 Final v1.0 FOR OFFICIAL USE ONLY - SENSITIVE Page 1 Released by DIBP under the Freedom of Information Act 1982 REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING To THE MENTAL HEALTH or DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE Contents 1. EXECUTIVE SUMMARY .. 3 Introduction .. 3 _1.2 Facts .. 3 _1.3 Findings ..4 2. Objective .. 5 3. Approach .. 5 4. InformatiOn Considered .. 5 5. Background Context .. 6 5.1. The Contract .. 6 5.2. Schedule 2 Statement ofWork to the Contract .. 7 5.3. Schedule 4.2-Governance ..7 5.4. Departmental Health Policy ..3 6. Analysis .. 9 5.1. Slide Pack Draft of 21 July 2014 .. 9 6.2. Statements .. 9 6.2.1 Introduction to Statements ..9 _6.2.3 Meeting Purpose and Outcome ..9 _6.3 Emails .. 13 Introduction to Emails .. 13 _6.3.3 Emails between DIBP and Dr Peter Young .. 13 Other Relevant Emails .. 13 Findings .. 13 11. Chronologv .. 13 7.2. Key Facts ..14 Key Findings .. 15 Timeline of Key Relevant Dates .. 16 Final v1.0 FOR OFFICIAL USE ONLY - SENSITIVE Page 2 Released by DIBP under the Freedom of Information Act 1982 REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING T0 1.1. 1.1.1. 1.1.2. 1.1.3. 1.1.4. 1.1.5. 1.1.6. 1.2. 1.2.1. 1.2.2. Final v1.0 THE MENTAL HEALTH OF DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE EXECUTIVE SUMMARY Introduction The Department oflmmigration and Border Protection contracted International Health Medical Services to deliver services wherein the primary objective includes provision of coordinated, high quality, evidence based health ca re of people in detention on the basis of clinical need and continuous improvement in the quality, effectiveness and efficiency of performance of health services. is the Health Services Manager under the contract. There are certain obligations of the Health Services Manager including in relation to duty of care; compliance with the service delivery model; consultation, collaboration and cooperation; and service obligations. The service obligations involve, amongst other things, collaboration and participation with DIBP the development and review of Department Health Policy, including by undertaking health research, preparing and analysing reports against Department specified health data sets and attending and contributing to committees, workshops and other meetings, as reasonably requested by the Department from time to time.? The contract includes a detailed statement of work and sets out the corporate and clinical governance arrangements that must be capable of fostering cooperative, coordinated and professional working relationships amongst other things. Particularly relevant is a requirement that the Health Services Manager must ensure that the mental health needs of People in Detention are adequately and appropriately identified, monitored and treated at all times by the conduct of mental health Under the contract, the Health Services Manager is required to develop, implement and manage policies, procedures and processes for the monitoring and periodic assessment of the mental health of people in detention. In particular, the contract requires that the screening instruments and methodologies be developed and implemented in consultation with and be incorporated in the Policy and Procedure Manual. The contract also requires the Health Service Manager to consider and use {as appropriate} the results or findings of mental health screening and assessments conducted to inform appropriate management strategies. These management strategies under the contract must be developed, implemented and reviewed collaboratively at the Departments option {and without impinging on any relevant professional or ethical requirements or laws]. Facts The facts establish that an iterative process was underway to improve the quarterly data sets reported to the department in relation to detainee health using the Bettering the Evaluation and Care of Health (BEACH) methodology. On 28 January 2014, the Medical Director, was given approval by the Director, Stakeholder and Health Strategy Section, DIBP to use HONOS and Kessler 10. At that time, the Medical Director, IHMS advised that it would also be usingthe corresponding child screening measures for minors. On 13 March 2014, the Medical Director, IHMS recognised that without official sign off at a more senior level within DIBP, IHMS could not vary the screening instruments approved under the contract. FOR OFFICIAL USE ONLY - SENSITIVE Page 3 a r: ?it. ?4 {l . - Fa sale a. I REPOR 1.2.3. 1.2.4. 1.2.5. 1.2.6. 1.3. 1.3.1. 1.3.2. 1.3.3. 1.3.4. 1.3.5. 1.3.6. 1.3.7. 1.3.8. 1.3.9. Final v1.0 INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING TO THE MENTAL HEALTH OF DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE On 27 June 2014, IH MS advised that the Health of the Nations Outcomes Scale for Children and Adolescents (HONOSCA) had recently been extended to minors in detention. Despite DIBP not having an obligation to do so. IHMS were given approval for additional resources to complete HONOSCA reviews in time for provision of data to the Australian Human Rights Commission the following Wednesday. As at 2 July 2014, the preposed mental health section of the new quarterly data set appeared [at officer level only between DIBP and to be agreed to include: . GP encounters methodology] . Pychotropic medications In Kessier 10 results 0 Torture and Trauma Disclosures Admissions to facilities Health of the Nations Outcomes Scales On 21 July 2014 IHMS provided a briefing to DIBP officials for the first time on HONOSCA data. In that presentation, IHMS noted limitations due to an incomplete data set, recent implementation and no subjective comparator. The outcome of that meeting was that IHMS agreed to further analyse and refine the data and that DIBP would undertake a more thorough review before making a decision on any change to the screening instruments. The facts establish that the issue being discussed between DIBP and IH MS was whether mental health screening instruments recommended by IHIVIS were appropriate to the detainee population; and secondly whether the interpretation of data sourced from those instruments. On 28 July 2014. DIBP requested IHMS to withhold HONOS and HONOSCA data from quarterly reporting pending further consideration and discussion. This is entirety consistent with requirements under the contract. Findings I make the following findings: The contract between IHMS and DIBP requires any proposed change to mental health reporting arrangements be deait with through a collaborative approach based on expert advice and clearly documented in policy and procedure. IHMS had not been provided with requisite approval underthe contract to change screening instruments used for analysis and reporting and IHMS knew this. The data presented on 21 My 2014 had limitations and was marked DIBP did ask IHIVIS on 23 July 2014 to withhold HONOS and HONOSCA data from the quarterly data set pending further consideration by DIBP and discussion with IHMS. DIBP did not ask IHMS to cease collecting data nor did it ask IHMS to cease using HONOS or HONOSCA screening instruments. DIBP noted that IHMS would need to provide data to the AHRC and in fact had contributed to the cost of collecting that data despite not being under an obligation to do so. DIBP did state to IHMS that it considered that the request was for data not commentary. The allegation that DIBP covered up health data is false. FOR OFFICIAL USE ONLY - SENSITIVE Page4 "ll l-l ll:- lill REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING T0 3.2. 3.3. 3.4. 3.5. 3.6. 4.1. 4.1.1. 4.1.2. 4.1.3. 4.1.4. 4.1.5. 4.1.6. 4.1.7. 4.1.8. 4.1.9. Final v1.0 THE MENTAL HEALTH OF DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE Objective To establish an agreed set of facts relating to the allegation that data relating to the mental health of detainees, particularly children, was covered up. Approach Persons in roles identified as relevant to the allegation were approached for written statements that they prepared and could attest to. Persons employed by the Department of Immigration and Border Protection (DIBP) were approached initially by email. Where clarification was required, this was done by email, telephone or one on one meetings. Initially, S. was telephoned to advise that information would be sought and to discuss how this might be done. This was followed up by email. A further email was then sent directly tos' and International Health and Medical Services employees. Where clarification, was required, this was done by telephone. In the case of Dr Peter Young, a phone call was made to seek his participation. This was followed up by a text message seeking his email address. An email was then sent to Dr Young seeking his statement. Where information obtained in the course of the preparation of this report identified further persons who might have relevant information, those persons were approached either by telephone or email or both. Following the drafting of the report, where content attributed information to that provided by an individual in their statement, a copy ofthat content was provided to the individual for comment on its accuracy and any feedback incorporated in this final report. Information Considered The main information considered in the preparation of this report consisted of: Health Services Contract between the Commonwealth of Australia and International Health and Medical Services Pty Limited {the Contract) dated 14 January 2009 IHMS Procedure 3.6.1 1.02 {June 14] IHMS Practice Guideline (Sep 2013] Policy Advice Manual 3 Detention Services Manual, Chapter 6 {versions since 14 january 2009 particularly 1 July 2009 and current] Statement from Michael Shelton, Director, Detention Health Contracts Section, DIBP dated 4 August 2014 Statement from Dr Paul Douglas, Chief Medical Officer, DIBP dated 4 August 2014 Emails from S. Regional Medical Director, dated 5 August 2014 and 2 September 2014. Statement from Amanda Little, Director, Detention Health Operations Section, DIBP dated 5 August 2014 Statement from Ian Campbell, Assistant Director, Detention Health Public Scrutiny and Reporting, DIBP dated 6 August 2014 FOR OFFICIAL USE ONLY - SENSITIVE Page 5 it"s-? -li L. .. . I..r - -y ale REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING To 4.1.10. 4.1.11. 4.1.12. 4.1.13. 4.1.14. 4.1.15. 4.1.16. 4.1.17. 4.1.18. 4.1.19. 4.2. 5.1.3. 5.1.4. THE MENTAL HEALTH OF DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY SENSITIVE Statement from Havlev Abbott, Acting Director, Offshore Health Service Deliver-t:l Section, DIBP dated 6 August 2014 and email dated 1 September 2014. Statement from Paul Windsor, Assistant Secretarv, Health Services Branch, DIBP dated 6 August 2014 Email from S. . National Operations Manager, IHMS dated 6 August 2014 Email from Ian Gilbert, Chief Operating Officer, IHMS dated 7 August 2014 Email from S. . Mental Health Services Manager, IHMS dated 8 August 2014 Statement from Ms Robyn Macdonald, Director, Stakeholder and Health Strategy Section, DIBP dated 8 August 2014 and email dated 2 September 2014. Email from S. dated 11 August 2014 Medical Director, Primary Health 8t Community Care, Statement from Mr John Cahill, First Assistant Secretary, Infrastructure and Services Division, DIBP dated 12 August 2014 and email dated 1 September 2014. Emails from Dr Peter Young, Consultant (formerlyr Medical Director}, IHMS dated 13 August 2014 and 1 September 2014. Email from Dr Paul Alexander, Special Adviser {to the Secretary of dated 18 August 2014 Additional information considered included emails between DIBP and officers that contained references to the quarterly data set and screening instruments. Background Context The Contract The contract is 749 pages in length incorporating 68 Clauses and 18 Schedules. The objective of the contract is set out at Clause 61. The primaryI objective includes the provision of coordinated, high quality, evidence based health care of people in detention on the basis of clinical need and continuous improvement in the quality, effectiveness and efficiency of performance of health services. is the Health Services Manager under the contract. There are certain obligation of the Health Services Manager including in relation to duty of care {ciause compliance with the service deliver model [clause consultation, collaboration and cooperation [clause and service obligations {clause 12]. The service obligations in clause 12 involve, amongst otherthings, collaboration and participation with DIBP the development and review of Department Health Policy, 7 including by undertaking health research, preparing and analysing reports against 1 Department specified health data sets and attending and contributing to committees, workshops and other meetings, as reasonably requested bv the Department from time to time.? (refer clause 12.10] at page 1 . . . . All references to clauses hereinafter are references to clauses In the contract and Its supporting schedules. Finalv1.0 FOR OFFICIAL USE ONLY - SENSITIVE Page 6 REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING T0 5.2. 5.2.1. 5.2.2. 5.2.3. 5.2.4. 5.2.5. 5.2.6. DJ 5.3.1. Final v1.0 THE MENTAL HEALTH 0F DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE Schedule 2 Statement of Work to the Contract Clause 2 sets out the corporate and clinical governance arrangements that must be capable of fostering cooperative, coordinated and professional working relationships; respecting and giving effect to competing values of medical impartiality, clinical autonomy and collaborative service delivery; and promoting and supporting effective Contract and relationship management. Key elements of the required system of clinical governance include a systematic approach to assurance and continuing improvement consistent with and in support of the performance ofthe contract. The Health Services Manager is required to prepare and comply with a Policy and Procedures Manual [clause 3). That manual is required to be reviewed and updated as necessary by 31 January each year. The Health Services Manager must prepare annually 3 draft forward looking Health Services Plan for approval by DIBP that amongst otherthings describes new {and continuing] quality and service delivery improvement initiatives or activities {clause 4.1.1igli. Further on in Schedule 2 there is specific reference to a requirement that the Health Services Manager must ensure that the mental health needs of People in Detention are adequately and appropriately identified, monitored and treated at all times by the conduct of mental health [clause 24.1.1) Clause 24.2.1 requires the Health Services Manager to develop, implement and manage policies, procedures and processes for the monitoring and periodic assessment of the mental health of people in detention and that such policies must be flexible, adaptable to change and consistent with and implement relevant Departmental Health Policy. In particular, that clause requires that the screening instruments and methodologies be described; their frequency and timing be specified; they be developed and implemented in consultation with DIBP and incorporated in the PPM developed under clause 3, Schedule 2. The use of mental health screening tools is further reinforced in the balance of clause 24 including that the Health Service Manager must consider and use {as appropriate} the results orfindings of mental health screening and assessments conducted to inform appropriate management strategies. The clause recognises that these management strategies must be developed, implemented and reviewed collaboratively at the Departments option (and without impinging on any relevant professional or ethical requirements or laws). Schedule 4.2 - Governance The Health Services Manager must appoint a Clinical Governance Team. Within that team various responsibilities are outlined including: The Regional Medical Director must collate and provide medical opinion advice in the format requested by DIBP (clause 4.2.2.2(Cll; and 0 The National Operations Manager must manage the development, review and update ofthe PPM and ensure that the Health Services are delivered in accordance with that manual {clauses 4.2.3 {al and FOR OFFICIAL USE ONLY - SENSITIVE Page 7 Released I in? 13/ DIBP and .x 51? 7C: In} 3? HIGH Ac Freedom of Inform REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING TO 5.3.2. 5.3.3. 5.4-. 5.4.1. 5.4.2. 5.4.3. 5.4.4. 5.4.5. 5.4.5. Final v1.0 THE MENTAL HEALTH OF DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY SENSITIVE The Director of Mental Health Services is responsible for: in partnership with the Medical Director, planning, developing, coordinating and evaluating mental health services in collaboration with relevant stakeholders (clause 4.2.4 ensuringthat relevant data is collected. monitOrEd. and to 35545" in planning {clauses 4.2.4 if) and lgll; ensuring that mental health clinical staff adhere to standard operating policies, procedures and processes {clause 4.2.4 The governance arrangements also provide for a Health Provider Committee Meeting with the specific purpose of discussing any matters relating to clinical issues, service delivery, contract management and operational details (clause Departmental Health Policy Relevant DIBP Health Policy is set out in the Detention Services Manual, Chapter 5 within PAM3. Section 1.2 ofthat chapter sets out the background to the revised approach that had applied since 28 February 2008. The background indicates that certain clinical processes and instruments were announced by government in September 2005 incorporating: - Mental state examination (MSE) - Health of the Nation Outcomes Scale (HONOS) - Kessler 10 self report questionnaire. The purposes and principles of screening (applying from 15 May 2009] are set out followed by the screening instruments. The instruments described in the chapter are: a MSE 1' General Health Questionnaire (GHCBO) 0 Depression Anxiety Stress Scale 0 Harvard Trauma Questionnaire The MSE is conducted as part of a Health Induction Assessment. A self-harm risk assessment interview may be conducted by the detention services provider during the reception process, priorto any health screening. This is not a "screening instrument" rather it is a "conversational style self-harm risk assessment interview specifically for use by non?health professionals in the detention environment. The chapter then describes to mental health screening process including a table that is populated with the Stage, Who, Timing and Process/Tools. For Stage 4, Specialist clinical assessment reference is made to the application of full MSE with the addition that the nature of the specialist clinical assessments will vary. At clause 4.8 ofthe chapter, it is noted that monitoring and evaluation of these arrangements will be essential, as no instruments have been validated for use in the detention environment. It is further noted that monitoring and evaluation will be heavily reliant on sound data. There is a specific section that addresses mental health policy application to minors and that care must be taken when applying this to minors. In recognition ofthe additional risk FOR OFFICIAL USE ONLY - SENSITIVE Page 8 "ll l-l [li- LL, HE REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING T0 5.4.8. 6. 6.1. 6.1.1. 6.1.2. 6.1.3. 6.1.4. 6.1.5. 6.1.6. 6.2. 6.2.1. 5.2.2. 6.2.3. 6.2.4. Final v1.0 THE MENTAL HEALTH OF DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE factors relating to minors additional advice is provided which is stated to override any information to the contrary provided in the mental heaith policies particularly mental health screening for people in detention. The additional advice in relation to assessment tools and screening instruments at clause 5.3 states that the findings of a MSE will determine whether the use of additional assessment tools is required and sets out when a minor should be referred to a child and adolescent child clinical The further assessment that is then undertaken is discretionary with certain instruments lists as a guide. It is noted that use of any tool requires informed consent from a parent, guardian or authorised delegate. it is also noted that the further advice on the support program for prevention of self harm states in relation to Principle 2: Clinically informed response that for cases involving minors. the most appropriate advice on risk, screening and treatment is available from clinicians with expertise in child and adolescent mental health. Analysis Slide Pack Draft of 2] luly 20 The slide pack consists of15 slides including the title page. Slides 2 to 7 provide background on HONOSCA Slide 8 describes limitations indicating that it is a good representative sample but an incomplete data set with only recently implementation {March 2014} and no subjective comparator. Slides 9 to 13 contain results Slide 14 has two conclusions Slide 15 makes five recommendations including that HONOSCA be added as a routine screen to MH (mental health} screening policy and that results and analysis be reported quarterly as part of the health data set. Statements Introduction to Statements Statements were obtained from each of the 13 persons who participated in the meeting on 21 July 2014. I have focussed my analysis on the meeting purpose and its outcome and any relevant circumstances leading up to that meeting. I have not addressed the tone ofthe meeting as it is not germane to the allegation that DIBP sought data to be withheld. sim ply note various participants had different perspectives ofthe level of negativity shown at the meeting although the body of evidence suggests that the tone was less cordial than previous meetings involving key participants. Meeting Purpose and Outcome The email statement from the convenor ofthe meeting, the Regional Medical Director for IHMS, s. confirms that IHMS first introduced HONOS inlanuary 2014 and HONOSCA in April 2014. 8- 47F(1)states that the purpose of the meeting on 21 July 2014 was to "provide DIBP with preiiminary information on the HONOSCA data." S. 47F(1)also states that both he and Dr Young commented during the meeting that they had "noted the FOR OFFICIAL USE ONLY - SENSITIVE Page 9 tutti-ale irf? if I i REPORT INTO AN ALLEGATIDN THAT COVERED UP HEALTH DATA RELATING TO 6.2.5. 6.2.6. 6.2.7. 6.2.8. Final v1.0 THE MENTAL HEALTH 0F DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE limitations of the study in the deck" and were presenting the data as they currently had it, "which was draft and preliminary?. S. 47F(1)understanding of the outcome of the meeting was that IHMS recommended that their next steps would be to use Child and Adolescent expertise from their network (they had a number of visiting specialists in this field) to review the data, further analyse it and compare it as necessary, compare it with the services that they provide and determine if they need to make any amendments to their services in the light of what the data was showing. S. 47F(1)states that asked IHMS not to do this and indicated that would engage a specialist with Dr Alexander to do this. IH MS agreed that they would further analyse the data and refine it to allow it to be sorted by ageflength of stay in detentionllocationfgender and ideally ethnicity. The email statement from Dr Peter Young, consultant to IHMS and previously Medical Director, Mental Health Services, IHMS (July 2011 to 4 July 2014) indicates he understood the primary purpose ofthe meeting was to advise of the outcomes of the mental health screenings before they were provided to the AHRC. Dr Young recorded that Dr Douglas and Dr Alexander were critical and dismissive of data presented. Dr Young felt that Dr Alexander was hostile in his tone, and directed that the conclusions and recommendations made in the presentation be redacted. Dr Young understood the outcome of the meeting to be that there would be further discussions about obtaining relevant child expertise and that IHMS would undertake further analysis of the results and present these to who would consider the findings and further actions. In a further email dated 1 September 2014, Dr Young notes that subsequent to the meeting on 21 July 2014, Ian Campbell [Assistant Director, Detention Health Public Scrutiny and Reporting] sent an email to IHMS indicating that further discussions about the screening results had occurred in the department and conveying the instruction that the child screening data from the as well as the adult HDNOS screening data [which had been previously agreed as included) be withheld from the IHMS quarterly health report until further notice. The email statement from Mr Ian Gilbert, Chief Operating Officer, IH MS indicates that the purpose of the meeting was to present initial findings of the HONOSCA data, demonstrate new reporting capabilities and provide clinical context to emerging health issues relating to children. He also understood there to be a secondary purpose to agree the approach to providing the data to the AHRC. Mr Gilbert indicates that there was some concern between clinicians, mainly about how the data was constructed and compared. Mr Glibert understood that took the draft recommendations on notice and that IHMS would present the information differently so that it could be broken down by smaller subsets. He understood that would then seek advice from Dr Alexander and his advisory panel and that IHMS recommendations would be considered after a more thorough review by The email Statement from S. Medical Director, Primary and Public Health, IHMS states that he understood the purpose of the meeting to discuss the HONOSCA results with S. understood the outcome ofthe meeting to be that Dr Young?s interpretation and recommendations were not accepted by who requested further analysis of the data. The statement from Dr Paul Douglas, Chief Medical Officer, describes the meeting on 21 July 2014 as being at the invite of IHMS for it to present recently collected data sets on mental health screening for children in detention to get an understanding of their role, the process of collection and some early results. Dr Douglas records that Dr Young explained FOR OFFICIAL USE ONLY - SENSITIVE Page 10 REPORT INTO AN ALLEGATION THAT DIBP covcaeo UP HEALTH DATA RELATING To 6.2.9. 6.2.10. 6.2.11. 6.2.12. Final v1.0 THE MENTAL HEALTH 0F DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE that HONOSCA was recently introduced and that IHMS were keen to show the department the early and preliminary findings. Dr Douglas also indicates that Dr Young felt the data was representative ofthe population, it was incomplete, only recently introduced and lacked a subjective comparator. Dr Douglas states that the meeting agreed that the data reflected that the cohort reported on appeared to have a higher level of mental health concerns than the general population. For reasons indicated in his statement, Dr Douglas states that the participants in the meeting did not believe the conclusions drawn could be justified. The outcome of the meeting according to Dr Douglas was that the recommendations would be taken on notice and that IHMS were to provide additional analysis with the cohort breaking down the figures by a range of factors. IHMS would also try and identify whether there was better data that would allow comparison between ?like?groups?. According to Dr Douglas? statement, Mr Windsor stressed at the end of the meeting that it was too early, whilst additional analysis was required, that HONOSCA data should form part of the quarterly dataset report and that none ofthe recommendations could be supported until further internal discussion ensued including the Independent Health Advisor liaising with his panel of experts. The email statement from independent Health Adviser, Dr Paul Alexander indicates that he participated by teleconference and only received the slide pack approximately 30 minutes before the meeting. Dr Alexander had no opportunity to discuss the results with third party experts prior to the teleconference. His recollection is that the first set of data had 50% non-compliance or incomplete data collection raising concerns regarding accuracy and ability to extrapolate. Dr Alexander considered an independent expert evaluation of the material was required and that he was unable to comment on the conclusions or recommendations without this. The statement from Mr John Ca hill, First Assistant Secretary, Infrastructure and Services Division indicates that he understood the meeting initiated by IHMS on 21 July 2014 to be one for interactive discussion and he was not expecting decisions out ofthat meeting regarding any particular methodology or mental health reporting instrument. Up to the point that Mr Cahill had to leave the meeting, he believed that further consideration would be required beyond the meeting and that this should have been obvious to participants. To be sure, however, as he left the meeting he directed his relevant Branch Head to ensure that participants were advised that the recommendations from Dr Young would be taken on notice for further consideration. Mr Cahill also states that no sense was conveyed whilst he was present that there was concern about the potential publication ofadverse data. The statement from Paul Windsor, Assistant Secretary, Health Services Branch, DIBP indicates that on 9 July 2014, Dr Parrish had initiated a brief teleconference to discuss preliminary HONOSCA results and it was agreed that a broader discussion should occur. This meeting was then set for 21 July 2014. Mr Windsor indicates there was vigorous debate at the meeting about the utility of the instrument and the comparability of the data. He states that both Dr Alexander and Dr Douglas made clear their views that DIBP was not yet in a position to clear the data for release in the way proposed by IHMS and that there was a need to understand better internally what the data was saying before considering adopting any ofthe recommendations. At the conclusion ofthe meeting, Mr Windsor states he made it clear that no decision would be made on the five recommendations. Mr Windsor confirms that DIBP subsequently asked to withhold FOR OFFICIAL USE ONLY - SENSITIVE Page 11 REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING TO 6.2.13. 6.2.14. 6.2.15. 6.2.16. 6.2.17. 6.2.13. 6.2.19. 6.2.20. 6.2.21. 6.2.22. 6.2.23. Finalvl? THE MENTAL HEALTH OF DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE new HONOS data from the upcoming quarterly report along with the HONUSCA data pending further consideration and discussion with IHMS. A number of other DIBP staff were present at the meeting of21 July 2014 and a summary ofthese follows. Michael Shelton. Director, Detention Health ContractsSection The purpose of the meeting was to discuss and make recommendations as to the HONOSCA findings. Mr Shelton had to leave the meeting at approximately 14:55 pm before it ended. At the time Mr Shelton left the meeting he was not satisfied with the level of information provided and was not convinced that the sample size and findings were sufficient to support the conclusions reached. Little, Acting Director, Offshore Health Services Delivery The purpose was understood to be for IHMS to present HONOSCA findings of a sample of children from held detention in Australia and at the Nauru Offshore Processing Centre. The slide pack was provided to Ms Little after the scheduled commencement of the meeting. The outcome was that lHI'v'lS would look at comparing results against a similar cohort, assess all children held in detention and incorporate findings within the data set. This would take a couple of months to complete. Mr Windsor took on notice the findings and recommendations for further consideration stating DIBP would like to see the results compared to a similar cohort. lon (.?otnpbell, .4 ssistont Director, Detention Heolth {Hill Reporting The purpose was to brief DIBP about a project it had undertaken to record and analyse child mental health data utilising the HONOSCA methodology. There was some discussion about the HONOSCA data to be provided to the AHRC. The key outcomes were that DIBP did not accept proposal to commence regular reporting of HONOSCA data and that IHMS were to provide DIBP with further disaggregation of the HONOSCA data. Hayley Illilmtt, Acting Director, O?'shore Health Services DelivervSectinn The purpose was for IHMS to present DIBP with HONOSCA findings of a sample of children from held detention. The outcome was that IHMS would look at comparing the results against a similar cohort and assess all children in held detention against the HONOSCA criteria (taking a couple of months to do so]. lHl'vlS were not to incorporate findings within the dataset. DIBP took on notice the findings and recOmmendations for further consideration. Robyn Mocdonohl, Director, Stakeholder and Health Strategy Section The outcome of the meeting was that IH MS would breakdown the data by age, length of detention and gender for analysis. IH MS were asked not to present the data [to the AH RC) as displayed in the report because of issues with inappropriate comparison (in her mind, being comparison of the HDNOSCA data oftransferees with HONOSCA data of the general Australian population). FOR OFFICIAL USE ONLY - SENSITIVE Page 12 Released by DIBP under the Freedom of Information Act 1982 REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING T0 6.3. 6.3.1. 5.3.2. 6.3.3. 6.3.4. 6.3.5. 6.3.6. 6.3.7. 6.3.8. 6.3.9. 6.3.10. 7. 7.1. 11.1. Fina v1.0 THE MENTAL HEALTH 0F DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE Emails Introduction to Emaiis A number ofemails were appended to some statements. Other emails were sourced directly from their authors. The key emails considered relevant to this matter are outlined in the following paragraphs. Emails between DIBP and Dr Peter Young On 28 January 2014 at 10:14 am, Dr Peter Young was sent an email from DIBP confirming a conversation that may commence using the new instruments (HONOS, immediately?. On 28 January 2014 at 10:42 am, Dr Peter Young sent an email re5ponse to DIBP saying that IHMS "would be putting in the corresponding child screening measures for minors". On 13 March 2014 at 11:20 am, Dr Peter Young sent an email to DIBP saying that: "we are still in a little bit of a limbo without official sign off from Paul Windsor on screening changes. We have not had formai instruction from Paul last week and unfortunately our contracts section has still been insisting that we cannot move to updated instruments until we have it." The emaii from Dr Young on 28 January 2014 could be read to refer to HONOSCA. The later email from Dr Young on 13 March 2014 appears critical as it is recognition In writing that IHMS were aware that the contract requirements had not been met and hence there was no authorisation to use either HONOS or HONOSCA (or K10 for that matter]. Other Relevant Emails During an exchange of emails between IHMS and DIBP in eariyJuly 2014, there was an email to Paul Windsorfrom Ian Campbell on 10 July 2014 at 4:18pm with the subject "mental health section of new data set". In that email, Mr Campbell states that the new data set will have information including the Health of the Nations Outcome Scale It had earlier been communicated to IHMS on 2 July 2014 {albeit initially that it was at their discretion to include HONOS but subsequently acknowledged to IHMS by DIBP tacitly at least} that would be including HONOS. It is not ciear why this communication was sent on 2 July 2014 given the previous authority provided on 28 January 2014. It appears from the evidence that senior departmental officers were not aware ofthe approval provided on 28 January 2014. On 28 July 2014, Mr Campbell asked Mr Windsor (during a discussion about HONOSCA data} whether HONOS should also be removed from the quarterly data set. Mr Windsor asked whether HONOS inclusion had been approved. Mr Campbell said no. On that basis Mr Windsor instructed Mr Campbell to ask to withhold both HONOS and HONOSCA data pending further consideration. This request was sent to IHMS on 28 July 2014 at 5:09pm. Findings Chronology The chronology at Appendix A sets out the timeline of key relevant dates. FOR OFFICIAL USE ONLY - SENSITIVE Page 13 Released by DIBP under the Freedom of Information Act 7 982 REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING T0 7.2. 7.2.1. 7.2.2. 7.2.3. 7.2.4. 7.2.5. 7.2.6. 7.2.7. 7.2.8. Finalvl? THE MENTAL HEALTH OF DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY SENSITIVE Key Fat-i The facts establish that an iterative process was underway to improve the quarterly data sets reported to the department in relation to detainee health using the Bettering the Evaluation and Care of Health (BEACH) methodology. As at 15 May 2009 to a current date, the approved screening instruments were: 0 l?v?lSE 0 General Health Questionnaire (GHQBOJ Ir Depression Anxiety Stress Scale I- Harvard Trauma Questionnaire On 28 January 2014, the Medical Director, IHMS was given approval by the Director, Stakeholder and Health Strategy Section, DIBP to use HONOS and Kessler 10. At that time, the Medical Director, IHMS advised that it would aiso be using the corresponding child screening measures for minors. On 13 March 2014, the Medical Director, IHMS recognised that without official sign off at a more senior level within DIBP, IHMS could not vary the screening instruments approved under the contract. On 271une 2014, IHMS advised that the Health of the Nations Outcomes Scale for Children and Adolescents (HONOSCA) had recently been extended to minors in detention. Despite DIBP not having an obligation to do so, IHMS were given approval for additional resources to complete HONOSCA reviews in time for provision of data to the Australian Human Rights Commission the following Wednesday. There was no request that the HONOSCA data be inciuded in the quarterly data set. As at 2 July 2014, the proposed mental health section of the new quarterly data set appeared agreed to have the following information: a GP encounters (BEACH methodology} 0 Pychotropic medications I Kessler 10 results 0 Torture and Trauma Disclosures I Admissions to facilities - Health ofthe Nations Outcomes Scales (HONOS) At a meeting on 21 July 2014 IHMS provided a briefing to DIBP officials for the first time on HONOSCA data using a power point slide deck marked DRAFT. There is not a consistent understanding between participants as to the purpose ofthat meeting. It seems ciear from the evidence that the purpose was to provide DIBP with the preliminary findings from screening done using HONOSCA with a view to recommending a way forward and discussing the provision of the data to the AH RC. Page 8 of that slide deck used at the meeting notes limitations due to an incomplete data set, recent implementation and no subjective comparator. The deck concludes with five recommendations including that HONOSCA and another instrument and Difficulties Questionnaire be added as routine screening policy with results and analysis reported quarterly. The outcome ofthe meeting was also not consistently understood by those present noting that at least two participants were not present to the end ofthe meeting. The evidence FOR OFFICIAL USE ONLY - SENSITIVE Page 14 the I ?t IP Freedom of ii?ifom r-?Hog? 7 REPORT INTO AN THAT DIBP COVERED UP HEALTH DATA RELATING To THE MENTAL HEALTH 0F DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE establishes that IHMS agreed to further analyse and refine the data and that DIBP would undertake a more thorough review before making a decision on any of the recommendations made. 7.2.9. The facts establish that the issue being discussed between DIBP and IHMS was whether newly recommended mental health screening instruments were appropriate to the detainee population and the interpretation of data sourced from those instruments. On 28 July 2014, DIBP requested IHMS to withhold HONOS and HONOSCA data from quarterly reporting pending further consideration and discussion. This is entirely consistent with requirements under the contract. Whilst IHMS were given approval at DIBP officer level to include HONOS in the quarterly data set from the end of January 2014 and, by implication, IHMS recognised by 13 March 2014 at the latestthat it had no authority under the contract to do so. 7.2.10. 7.3. Key Findings 7.3.1. Based on all of the evidence, I find that: The contract between IHMS and DIBP requires any proposed change to mental health reporting arrangements be dealt with through a collaborative approach based on expert advice and clearly documented in policy and procedure. - IHMS had not been provided with requisite approvai underthe contract to change screening instruments used for analysis and reporting and IHMS knew this. I The data presented on 21 July 2014 had limitations and was marked - DIBP did ask IHMS on 28 July 2014 to withhold HONOS and HONOSCA data from the quarterly data set pending further consideration by DIBP and discussion with IHMS. DIBP did not ask IHMS to cease collecting data nor did it ask IHMS to cease using HONUS or HONOSCA screening instruments. It DIBP noted that IHMS would need to provide data to the AHRC and in fact had contributed to the cost of collecting that data despite not being under an obligation to do so. DIBP did state to IHMS that it considered that the AH request was for data not commentary. 0 The allegation that covered up health data is false. Finaivl? FOR OFFICIAL USE ONLY - SENSITIVE Page 15 Released by DIBP under the Freedom of line/matron 7982 REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING TO THE MENTAL HEALTH OF DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE Timeline of Key Relevant Dates Date Description 14 Jan 09 Contract signed 15 May 09 DIBP Policy updated in PAM (Detention Manual Chapter 6 being the operative and most relevant section) 9 Nov 12 Letter from Dr Peter Young, Medical Director, to Paul Windsor, Assistant Secretary, Detention Health Services Dec 12 Detention Health Advisory Group including its Mental Health Sub-Group disbanded. 5 Feb 13 Mentai Health Su b-Group of the former DHAG met. Dr You rig presented suggested amendments to mental health screening documents. Professor Louise Newman AM {Chair} notes that discussion with DIBP was needed to further consider and approve any amendments which may be necessary to policies and the Health Services Contract as well as any consequential implications. Apr 13 Letter from Paul Windsor to Dr Peter Young. 3 Jul 13 Mentai Health Sub-Group of the Immigration Health Advisory Group met and agreed that screening instruments wouid be reviewed as part of their work pian. Jan 14 IHMS introduced HONOS and K10 to replacing previous tools on the basis that they were less appropriate for "screening" of the population. DIBP had not provided authority pursuant to the contract for this. 23 .Ian 14 IH MS responded to the 'approvai' provided by the Director of Mental Health Strategy Section, DBP advising it would also be putting in the corresponding child screening for minors. DIBP did not respond to this. 13 Mar 14 IHMS advise DIBP that as they had not had formal instruction from Paul Windsor, their contracts section insist they cannot move to updated instruments. Mar 14 Dr Paul Alexander begins participating in meetings and discussions following the announcement in December 2013 of his appointment as Independent Health Adviser 3 Apr 14 Ongoing discussions commenced between IHMS and DIBP staff regarding improving mental health data reporting to enable more meaningful comparisons and trend analysis between detainee data and outcomes for the Australian community. Discussion centred on using ?attering the Evaluation and Core of Heoith (BEACH) methodology, which is a system wideiy used in general practice to collect (SP?patient encounter data. HONOSCA was not mentioned in these discussions. 11 Apr 14 DIBP staff met with IHMS to discuss the composition of quarterly health data? sets. inclusion of HONDS data was not discussed at this meeting. Apr 14 IHMS introduced HONOSCA. 11 May 14 IHMS provided DIBP with the Quarterly Health data-set forthe Jan-Mar 2014 period. This report was the first to include HONOS {Adult} data. The introduction to the report states HONDS was introduced as a routine outcome measurement during that reporting period. 27 June 2014 advised DIBP HONOSCA recently extended to minors in detention. DIBP approved temporary increase in staffing at several Immigration Detention Facilities in order to complete HONOSCA screening. Final v1.0 FOR OFFICIAL USE ONLY - SENSITIVE Page 16 tli'iv?7l?sale REPORT INTO AN ALLEGATION THAT DIBP COVERED UP HEALTH DATA RELATING TO THE MENTAL HEALTH OF DETAINEES PARTICULARLY CHILDREN. FOR OFFICIAL USE ONLY - SENSITIVE Date Description 2 July 2014 DIBP staff discuss production ofa revised quarterly detention health data set (including a mock?up of the mental health section}. IHMS Clinical Reporting were advised by email of what the department would like including the advice that: ?At IHMS discretion as to whether to include GHQ and HONOS [though the GHQ doesn't seem to be very enlightening). 2 July 2014 Dr Young confirms various aspects of the mental health reporting saying HONOS definitely and that there needed to be paired subjective and objective measures}. 9 July 2014 IHMS initiates a brief teleconference with DIBP to discuss preliminary HONOSCA results. It was agreed that a broader discussion should occur that included the Independent Health Adviser DIBP Chief Medical Officer (CMO) and First Assistant Secretary Detention Infrastructure and Services Division. 21 July 2014 IHMS presented a DRAFT slide pack via teiecon (no papers/data were provided in advance}. CMO and IHA dialled in and FAS attended for part ofthe presentation. There was vigorous debate regarding the utility of the instrument and comparability of the data. Issues discussed included the cultural sensitivity of the instrument, whether scores from this cohort could be compared with scores for the general Australian population or whether it was more meaningful to compare against a non?detained asylum seeker/refugee background cohort {eg recently arrived humanitarian entrants). There was also discussion of whether it was appropriate to compare the results with the mean score at discharge for specialist Australian Child and Family Mental Health Services. At this meeting IHMS was explicitly advised that the five recommendations summarised in the handout presentation provided by IHMS at the meeting would be taken on notice. The third recommendation was: "Results and analysis reported quarterly as part of health data set". At the conclusion of the meeting it was agreed that IH MS would do more work on how the data might be broken down further (eg by age, time in detention, ethnic background, UAlvls, and gender) and whetherthere were more meaningful cohorts against which the results could be compared, eg recently arrived non detained asylum seekerfhumanitarian entrant cohorts. Immediately following the meeting, the IHA separately advised of concerns regarding the utility ofthe data and reinforced that should consider giving further consideration to the proposed approach before it was adopted in isolation from other relevant measures. 23 July 2014 Although recommendations from the meeting of 21 July were not agreed; no contract authorisation had been provided; and that further discussion and consideration of the issue was expected; DIBP understood from regular contact with IHMS that IHMS was intending to include both and HONOS data in the Apr?Jun data set {due 31 July 2014]. Consistent with the outcome of the meeting of 21 July 2014, and the contract DIBP requested to withhold this data from the quarterly data sets pending further consideration by DIBP and discussion with IHMS. Final v1.0 FOR OFFICIAL USE ONLY - SENSITIVE Page 17