Relevant narrative of events
19 The applicant is in his early thirties. He was taken to Nauru in August 2013 and was recognised as a refugee by the Government of Nauru in December 2018. Therefore, he has been on Nauru for almost six years. He possesses a visa, granted by the Nauruan Government, which, as contemplated by the offshore processing arrangements, is granted to those individuals who are recognised as refugees under the Refugees Convention. Nauru became a signatory to that Convention in 2011, only shortly before the current offshore processing arrangements commenced.
20 It is common ground on this application that the visa held by the applicant entitles him, under Nauruan law, to remain in Nauru, but also to leave Nauru and re-enter. Counsel for the respondents submitted the respondents accept there is no legal impediment to the applicant leaving Nauru. He submitted the impediments were "practical". Whilst I do not necessarily accept the distinction as it was made by counsel, the Court proceeds on the basis of the respondents' agreement that the applicant's visa entitles him to leave and re-enter Nauru.
21 This matter first came before this Court by way of an interlocutory application on 6 June 2019. Prior to the proceeding being issued in this Court, the applicant's solicitors and legal representatives at the Human Rights Law Centre (HRLC) had attempted to persuade the respondents that the preconditions existed for an exercise of power under s 198E of the Migration Act, one of the so-called "Medevac provisions". Those attempts were at that stage unsuccessful, despite the provision of expert reports from Dr Andrew Bezzina, an emergency physician, and Dr Hannah Lake, a consultant psychiatrist. Each had provided a report on the applicant's medical and psychiatric conditions, the treatment he was (or was not) receiving on Nauru, and what in their expert opinion was likely to happen to the applicant if he was not transferred off Nauru. Those reports were prepared after the practitioners' review of the medical records relating to the applicant which are kept by the Commonwealth-contracted medical treatment provider in Nauru, International Health and Medical Services (IHMS). It was not possible for those experts to have a consultation directly with the applicant, even by a method such as Skype or telephone. The Government of Nauru had taken action to ensure such consultations could not occur, by the making of regulations which prohibited such consultations: see the Health Practitioners (Telemedicine Prohibition) Regulations 2019 (Nr).
22 On 6 June 2019, no substantive orders were made by the Court, on the basis of the applicant's apparent lack of cooperation with the undertaking of an assessment by IHMS. The Court accepted it was necessary for IHMS to refer the applicant to what was submitted to be a necessary step in the transfer process: consideration by Nauru's OMR Committee of the question whether the applicant should be permitted to leave Nauru for the purpose of medical treatment.
23 The Court encouraged the applicant's solicitors to see if they could persuade the applicant to cooperate with IHMS, and the applicant's solicitors agreed to attempt to do that. I note the expert report of Dr Lake dated 5 June 2019 in particular explains why that was not an easy step to ask the applicant to take and why his apparent lack of cooperation with IHMS, and with mental health services more generally, is part of his illness. Dr Lake explains it thus in her report:
[The applicant] appears to have disengaged from mental health services.
[The applicant's] disengagement from mental health services represents a marked deterioration in his condition.
…
[The applicant] has been very clear in recent months that he does not feel mental health services, including admission to RPC-1, is helpful to him. In fact, he has declined significantly despite outreach. This is in keeping with my formulation of his current illness…
24 Subsequently, the applicant did cooperate sufficiently for IHMS to conduct an assessment of him and refer his case to the OMR Committee, although, due to circumstances to which Ms Troup deposed in her second affidavit, neither the applicant's solicitors, nor any other nominated person, was able to support him during that process. I should note here that Ms Troup deposed in her first affidavit that the applicant presently has no family on Nauru.
25 On 10 June 2019, the applicant's solicitors were informed by the respondents' solicitors, the Australian Government Solicitor (AGS), that IHMS was referring the applicant's case to the OMR Committee for consideration. The AGS informed the applicant's solicitors that "there may not be enough time for that to occur" at the OMR Committee meeting scheduled for that same week.
26 The next day, the applicant's solicitors were informed that a decision had been made to exercise the power conferred by s 198B of the Migration Act, to temporarily transfer the applicant to Australia for medical and psychiatric treatment. The relevant correspondence from the AGS stated:
We are instructed that the Department of Home Affairs has approved the temporary transfer of the applicant to Australia for medical/psychiatric assessment and treatment under s 198B of the Migration Act 1958. As you know, that approval is subject to the approval of the transfer by the Republic of Nauru Hospital's OMR Committee and uplift approval from the Government of Nauru.
As we informed you yesterday, IHMS has agreed to refer the applicant's case to the OMR Committee and the next OMR Committee fortnightly meeting is scheduled this Thursday 13 June 2019. The Department has asked IHMS to confirm whether there is enough time for the applicant's case to be referred to this week's OMR Committee meeting, but has not received a response from IHMS as yet.
We will let you know as soon as we receive instructions.
27 The applicant's solicitors had pressed for the applicant to be examined by an independent psychiatrist, or to be provided with an independent third person to assist in his engagement with IHMS, given the breakdown of his trust and relationship with IHMS. That suggestion was not taken up.
28 The OMR Committee did not make a decision on the applicant's transfer on 13 June 2019. That prompted the applicant's solicitors to return to the Court. On that occasion (14 June 2019), the Court accepted that, given the decision made under s 198B, it was appropriate to make orders including the order I have set out at [1] above, in light of the fact that the OMR Committee had not made any decision about the applicant's transfer the day before.
29 I emphasise that order was made both despite the fact of the s 198B decision, and also in a way because of it. In other words, on the evidence, the Court was persuaded a mandatory transfer order should be made, even though the respondents had indicated there was an administrative decision made a few days earlier to transfer the applicant.
30 No transfer occurred. I note that at the time the Court made its orders on 14 June, several weeks had passed since the respondents were first informed about the expert opinions of Dr Bezzina and Dr Lake.
31 What follows are excerpts of some of the opinions in those reports. Dr Bezzina stated:
I am of the opinion that [the applicant] is manifesting illness both from a mental health perspective and medically. His major and most pressing issue is his mental health and remains a risk to his life.
His medical issues remain incompletely explored despite symptoms and abnormal findings over a period of years. There remains potential for currently undiagnosed metabolic issues that may cause renal dysfunction over time.
Furthermore, some of his current and intermittent management options are contributing to, if not completely responsible for, additional medical issues.
32 Dr Bezzina also stated:
Premised on what is evident in the medical record and without a capacity to examine [the applicant] directly it is not clear that at this stage [the applicant] is receiving appropriate care. He is certainly not receiving effective care with respect to his psychological issues and he is certainly not receiving thorough care regarding his medical issues and their underlying causes as outlined above.
…
… I believe it is necessary to bring [the applicant] out of Nauru in order to complete those assessments and determine an effective pathway forward that avoids the risk of suicide and removes concern regarding his renal function and upper gastrointestinal issues.
33 Dr Lake stated in her report dated 18 May 2019:
[The applicant] is clearly suffering from a major depressive illness with psychotic features, however he requires a longitudinal inpatient assessment by a psychiatrist to determine what treatment is appropriate. He will need a medication review to determine what pharmacotherapy may be next trialled. He will need to be assessed for potentially requiring electroconvulsive therapy (ECT). When he is sufficiently recovered from this illness the diagnosis of acquired brain injury can be explored. This would involve cognitive testing and potentially imaging such as MRI Brain.
An extensive assessment of his suicidality and risk of self-harm is required urgently.
34 Dr Lake also stated in that report, including typographical errors in the original:
[The applicant] is high risk for completed suicide. I cannot see that [the applicant] has a future if he remains on Nauru. Indefinite detention and other linked psychosocial circumstances are clearly powerful predisposing, precipitating and perpetuating factors in his severe illness and he cannot recover while he remains in this situation. He not recover and instead almost certainly continue to deteriorate. [The applicant] will require a full medical history and examination, and investigation into his state of physical health.
…
[The applicant] requires immediate containment and monitoring in an inpatient unit, to manage suicide risk and his physical health. [The applicant] is at high risk of completed suicide.
…
The assessment and treatment he has been receiving is far from what is required and profoundly less than the care he would receive in Australia. The most basic assessments have not been conducted including regular weights, postural blood pressure and cognitive testing.
35 She continued on the next page, including typographical errors in the original:
[The applicant] has been on a deteriorating trajectory for several years. The care of his psychiatric condition appears to have plateaued.
[The applicant] reports deep hopelessness regarding his future. This appears to be a significant driver of his illness. [The applicant's] illness cannot be adequately treated unless this is addressed. I do not believe that there are adequately facilities or services in Nauru to reliably and consistently deliver the intensive care that [the applicant] requires. Given the high level risk of fatal consequences of [the applicant's] mental illness (by suicide), [the applicant] requires urgent transfer to a facility that can unambiguously meet his significant health care needs.
36 In her report of 5 June 2019, Dr Lake stated:
In my previous report I stated that [the applicant] is clearly suffering from major depressive disorder with psychotic features. The updated information that I have received is in keeping with this opinion, and points to a marked deterioration in his illness.
…
I state in the strongest possible terms that [the applicant] is at very high risk of completed suicide. His risk is higher than it was at the time of my previous report, as at that time he was maintaining a (tenuous) therapeutic relationship with mental health services. He is now completely socially isolated, suffering a psychotic depression with command auditory hallucinations to commit suicide, and has a recent history of attempting suicide.
My treatment recommendations per my previous report still stand. The urgency for these actions to be undertaken has escalated. Again, [the applicant] is at imminent risk of completed suicide. He requires transfer from Nauru immediately and without further delay.
(Original emphasis.)
37 On 18 June 2019, the applicant's solicitors inquired of the AGS about when the applicant would be transferred, and what steps had been taken to give effect to paragraph 2 of the Court's orders made on 14 June 2019. The response received on 20 June 2019 from the AGS should be reproduced in full:
CEU19 ([the applicant]) VID600 of 2019
We refer to your letter of 18 June 2019.
The respondents are conscious and respectful of the orders made by his Honour on 14 June 2019. As you know, the Department of Home Affairs (the Department) has already approved the temporary transfer of the applicant to Australia under s 198B of the Migration Act 1958 (Cth).
However, the Government of Nauru requires all overseas medical transfers to be approved by the Republic of Nauru (RoN) Hospital's Overseas Medical Referral (OMR) Committee. That process, including the importance of the Australian Government respecting that process, was explained in detail in the affidavit of Acting Assistant Commissioner Peter Timson (the Timson affidavit) filed by the respondents in this proceeding. Further, the Department or respondents have no part or power in the OMR Committee's decision making process, which is now enshrined in the Nauru law: see paragraphs 65 to 67 of the Timson affidavit).
The OMR Committee meets fortnightly. As you know, the last OMR Committee meeting took place on 13 June 2019. We had informed you previously that there may not be enough time for the applicant's case to be presented at that meeting given that he did not agree to be assessed by an IHMS psychiatrist until 9 June 2019 (noting that IHMS is responsible for referring and often presenting the cases to the OMR Committee: see paragraph 33 of the Timson affidavit).
We are however instructed that the applicant's case has formally been referred to the OMR Committee's chair for the committee's consideration. The Department anticipates that the case will be considered at the next OMR Committee meeting on 27 June 2019.
We are instructed that the Department has considered at senior level what reasonable steps the respondents might be able to take before the next OMR Committee meeting to effect the applicant's transfer to Australia. Given in particular that presently there has been no delay in the consideration of the applicant's case by the OMR Committee, it is considered that any steps that the Department might take at this stage are likely to be of no utility and are likely to be counterproductive because they would be perceived by the Government of Nauru as interference with their processes and therefore disrespectful to their sovereignty. The Timson affidavit explains in detail the importance of the Australian Government respecting the Nauru processes and contains numerous examples of the counterproductive effect previous attempts to circumvent those processes have had on the relationship with the Government of Nauru. As a result, after careful consideration, a decision has been made not to take any steps before the likely consideration of the applicant's case at the next OMR Committee on 27 June 2019.
Should the OMR Committee approve the applicant's overseas medical transfer on 27 June 2019, the Department will take all reasonable steps to effect that transfer as soon as practicable including to obtain the uplift approval from the Government of Nauru, arrange flights and receiving care in Australia for the applicant. Should the OMR Committee refuse, or not consider, the applicant's transfer to Australia at the next meeting, the Department will at that stage urgently again consider what reasonable steps are available to the respondents to progress the transfer.
Meanwhile, we are instructed that IHMS continues to regularly monitor the applicant by way of outreach visits to his home. His latest clinical record is attached in that regard. IHMS has informed the Department that the applicant was offered admission into the Supported Accommodation Area as recommended by Dr Mohanraj (the IHMS psychiatrist who examined the applicant on 9 June 2019), but the applicant has declined that offer.
We also note that the IHMS has informed the Department that the applicant did not attend a scheduled psychiatry review yesterday. They have advised that they will attempt to reschedule the appointment at the applicant's home. That is also relevant to the email from your office dated 12 June 2019 complaining, amongst other things, about the applicant's case worker from the Australian Refugee Resource Centre not being present (by phone) during the applicant's psychiatric examination on 9 June 2019. IHMS has since confirmed that they did not permit the case worker to be present for the reasons set out in our emails to you dated 9 and 10 June 2019. We note that this is IHMS's clinical decision over which the Department has no control. If you wish to query this further in relation to appointments going forward, we suggest that you contact IHMS directly.
If you wish to discuss anything please contact the writer.
38 On 25 June 2019, the applicant's solicitors were advised that the HRLC had been notified of another decision relating to the applicant, this time a decision made by the first respondent under s 198E of the Migration Act:
I wish to advise that the Minister for Home Affairs (the Minister) has approved [the applicant's] transfer to Australia under section 198E of the Act.
As the Minister has approved the transfer of [the applicant] to Australia under section 198E of the Act, the Department will, as soon as practicable, bring [the applicant] to Australia for the temporary purpose of medical or psychiatric assessment or treatment.
Please be aware that prior to transfer to Australia it will necessary to obtain all required local approvals from the Government of Nauru.
39 At this point, the applicant's solicitors foreshadowed a further application to the Court, and received a response from the AGS indicating the respondents did not presently intend to take any further steps to transfer the applicant, pending the outcome of the OMR Committee meeting on 27 June 2019.
40 One of the other issues dealt with in this correspondence was whether the OMR Committee would be provided with the reports of Dr Bezzina and Dr Lake. The evidence before the Court suggests this is a sensitive issue for the OMR Committee.
41 The AGS relevantly stated in its correspondence:
When asked whether they provided the OMR Committee with the two reports of Dr Lake and the report of Dr Brezzina, IHMS responded to the Department as follows:
IHMS provided a comprehensive and appropriate clinical briefing to the OMR Committee regarding [the applicant's] case. The OMR Committee was briefed on the external medical documents attached to your e-mail, but did not request a copy.
As you are aware the OMR committee objects to attempted legal intervention from Australia and attempted intervention from external medical practitioners, who are neither registered in nor practice in Nauru, into Nauruan medical care and other internal Nauruan processes.
To provide such documents to the OMR committee without request from the committee would be viewed unfavourably by the committee and be counter-productive in achieving an optimal clinical outcome. It would also adversely affect professional relationships between IHMS and the RoN.
42 On 27 June 2019, the day the OMR Committee meeting was scheduled to take place, the applicant's solicitors wrote to the AGS to foreshadow the kind of orders they would seek from the Court if the OMR Committee did not consider the applicant's case or approve the applicant's transfer:
If the OMR Committee does not consider our client's case at tonight's Committee meeting, or if the OMR Committee reaches a decision that is unfavourable to our client, we will make an urgent application to the Court seeking the following orders:
• That the Commonwealth urgently make an application to the Nauruan Minister of Health and/or Nauruan Ministry of Multicultural Affairs to have the OMR Process dispensed with; and/or
• That the Commonwealth urgently seek to secure "uplift approval" for our client within the meaning of paragraph [50] of the affidavit of Mr Peter Timson sworn on 6 June 2019.
43 In his second affidavit, Mr Timson described what happened at the OMR Committee meeting on 27 June 2019:
The applicant's case has been held over pending Dr Smith, the Medical Officer with responsibility for psychiatric matters at the Republic of Nauru Hospital, conducting a medical assessment of the applicant, which is scheduled for 3pm on 3 July 2019. Dr Smith's report would subsequently be provided to the OMR Committee. The OMR Committee is expected to meet again on Thursday 11 July 2019.
44 I note the evidence is that the OMR Committee is "expected" to meet on 11 July 2019. Mr Timson's overall evidence supports the qualified way in which he expresses himself in this paragraph. On the evidence as a whole, the OMR Committee's conduct, in terms of both its scheduling of meetings, and its decision-making, appears to have some unpredictability about it.
45 I should at this point mention two other pieces of evidence. Ms Troup deposed to having received a communication on 28 June 2019 from Dr Beth O'Connor, a psychiatrist who worked on Nauru with Médecins Sans Frontières (MSF) from October 2017 to September 2018. MSF provided mental healthcare to asylum seekers and refugees who had been transferred to Nauru pursuant to Australia's offshore processing arrangements, and also to Nauruan nationals, but was compelled to leave Nauru by the Nauruan Government in October 2018.
46 Dr O'Connor stated that, when she was working on Nauru, Dr Smith informed her that he had qualified as a doctor and had two years of postgraduate mental health training in Fiji, but that he had not obtained the qualification of a psychiatrist. The respondents did not dispute this evidence.
47 Dr Smith was the practitioner who also played a role recently in the apparently so far unsuccessful attempts to transfer another individual from Nauru known, by reason of his proceedings in this Court, as CCA19. Orders have been made by this Court in relation to CCA19's predicament, however, at the time of the Court's hearing on 1 July 2019, he also remained on Nauru. Ms Troup deposes in her second affidavit, on information and belief, that:
In the case of CCA19 v Minister for Home Affairs [2019] FCA 939, the OMR Committee also required the applicant in that matter to be reviewed by Dr Smith before Dr Smith reported back to the OMR Committee with the outcome of his review. In that proceeding:
(a) The OMR Committee said that it needed a report from Dr Smith on 16 May 2019, in order to consider the applicant's case at the OMR Committee meeting scheduled for 30 May 2019;
(b) On 30 May 2019, the OMR Committee again said that it required a report from Dr Smith, which had not yet been provided, and adjourned until 13 June 2019 for the purpose of receiving his report;
(c) The Court was told on 13 June that no written report had been prepared by Dr Smith as at that date and that instead, the OMR Committee would meet and receive an oral report from Dr Smith; and
(d) Dr Smith did not show up to the OMR Committee's meeting on 13 June and as a result, the decision of the OMR Committee with regards to the applicant's transfer to Australia was not made that day.
48 Ms Troup also deposes that at the time of affirming her second affidavit, she was informed there is still no indication that Dr Smith has provided a report in respect of the applicant in CCA19.
49 Again, this evidence was not disputed by the respondents.