The death of an Iranian asylum seeker from an infection contracted on Papua New Guinea's Manus Island was preventable, an Australian coroner has ruled, in a report that identified a multitude of bureaucratic bungles and healthcare inadequacies.
Hamid Khazaei, who was 24, died when his life support was switched off at a Brisbane Hospital in September 2014, twelve days after he had gone to a clinic at Australia's asylum seeker detention centre with a simple infection in his leg.
In a 131-page report, the Queensland Coroner, Terry Ryan, identified several systemic flaws in the healthcare provided for those detained by Canberra on remote islands in the Pacific.
Among the flaws was the fact the clinic at Manus, an equatorial island in the north of PNG, did not have the antibiotics needed to treat tropical infections, and a series of delays in transferring patients who need hospital care off the island.
Mr Ryan found Australia's Department of Home Affairs needed to enforce new policy that put the clinical needs of detainees first, and called on the federal Attorney General to establish a new framework to ensure independent judicial investigations of deaths in Australia's offshore detention system.
"I am satisfied that if Mr Khazaei's clinical deterioration was recognised and responded to in a timely way at the [detention centre] clinic, and he was evacuated to Australia within 24 hours of developing severe sepsis, he would have survived," Mr Ryan said.
A Litany of Errors
Hamid Khazaei was born in Iran in 1990. He grew up, served 18-months of military service, and then worked as a salesman in Tehran.
But in mid-2013, according to evidence in the coroner's report, he found himself in a conflict with a cleric. Fearing torture and imprisonment, he paid to be smuggled from Iran to Indonesia.
In August 2013, he set off from Indonesia in a rickety boat, the Gadsen, bound for Australia, where he hoped to claim asylum.
But under Australia's strict immigration laws, any asylum seeker who tries to reach the country by boat will be denied resettlement, no matter how dire their circumstances, and will instead be flown to detention centres in Nauru or Papua New Guinea.
The hardline policy, which was introduced in 2013 by Labor Prime Minister Kevin Rudd, and then tightened by the Liberal governments of Tony Abbott and Malcolm Turnbull, has been heavily criticised by human rights groups, refugee lawyers and even the United Nations, which has said it violates international refugee law.
But it has popular support in Australia, where immigration - especially by boat - has proved a flashpoint issue, and where both parties remain committed to the policy in some shape or form.
Mr Khazaei's boat sailed head-first into the newly-reintroduced policy, and when it was intercepted by Australian authorities, he was taken to Christmas Island. As a single man, Mr Khazaei was then flown to detention on PNG's Manus Island.
There, he was detained with hundreds of other men, mostly from the Middle East and Southeast Asia (Families, women and children were detained on Nauru). By all accounts, Mr Khazaei was a quiet, yet popular, man who drew no trouble.
He was fit and healthy, according to accounts contained in the coroner's report. But on 23 August 2014, he presented to the detention centre's medical clinic with what appeared to be a routine infection of a cut in his leg.
The clinic at the time was run by the multinational company, IHMS.
Doctors gave him some antibiotics and kept him in the health centre for observation. But over the course of the next day, he developed a fever, body aches and chills. His blood pressure slowed to what doctors said was a worrying level.
After 36 hours, Mr Khazaei's condition continued to deteriorate, and the doctors repeatedly requested that he be urgently transferred out of Manus for hospital treatment, saying there was a spare seat - and a supervising doctor - on a flight to the capital, Port Moresby that afternoon.
That flight was missed because the request was ignored for several hours and then refused before approval was finally granted to take Mr Khazaei, who was now semi-conscious and septic, to Port Moresby's Pacific International Hospital.
"There was a number of significant flaws in the arrangements for Mr Khazaei's transfer from the [detention centre], including a lack of a documented approval process, resulting in a missed opportunity," Mr Ryan said in his findings.
When Mr Khazaei arrived at Pacific International Hospital, a private institution, the neglect continued.
He was wheeled into the emergency department, where he was left largely unattended behind a curtain. "Despite him being so unwell, there seemed to be absolutely no sense of urgency from the … staff," a nurse told the inquest.
"It seemed the staff at the PIH either did not realise how ill the patient was, or if they did, they did not know what to do," she said.
Later on the evening of 26 August, the decision was finally made to intubate Mr Khazaei and move him to intensive care. But the intensive care unit was up a level, and there was no internal lift at the hospital. To move him would involve wheeling him up a steep ramp outside, which was impossible in heavy rain.
Mr Khazaei would remain in intensive care for several more hours until the rain stopped.
Mr Khazaei was then misdiagnosed with pulmonary oedema, or excess fluid in the lungs which, according to one doctor who gave evidence, required "basically the opposite medical management" of septic shock and multiple organ failure, which is what Mr Khazaei had.
Finally, IHMS managed to rally a team of Australian physicians who were in Port Moresby for an Australian Federal Police (AFP) programme.
That team arrived at the PIH and took over treatment. One of the team, in his evidence, said they did not know where Mr Khazaei was, found no records of his past treatment or condition, and when they finally found him in the corner of the Intensive Care Unit, monitor alarms were going off but no one was attending to him with any urgency.
The bag helping Mr Khazaei breathe was broken, and one of his intravenous lines was inserted beside his vein, not in it.
Just after 10pm that night, Mr Khazaei went into cardiac arrest. The AFP team stabilised him and made the call for an urgent medivac to Australia, which happened just after midnight.
On August 27, Mr Khazaei arrived at Brisbane's Mater Hospital. He was unresponsive. He was declared brain dead five days later and, on 5 September, his life support was switched off.
"Mr Khazaei's death was preventable," said Mr Ryan. "His death was the result of the compounding effects of multiple errors rather any significant action or inaction."
"This included the failure to ensure the Manus Island Regional Processing centre had antibiotics available to safely treat [his] leg infection, the failure to adequately detect and report a severely deteriorating patient, inadequate clinical care and processes … ineffective processes for the transfer … and the unfortunate expectation that adequate and intensive critical care could be provided at Pacific International Hospital."
In his finding, Mr Ryan found that Australia had sole responsibility for Mr Khazaei's care and for the failures that led to his death, recommending that the standard of treatment for detained asylum seekers be brought up to Australian standards.
"It is incumbent on the Australian government to implement sustainable systems for the delivery of health care that meet the requisite standard," he said.
In his eight recommendations, Mr Ryan said doctors should have greater control of patient transfers to hospital care in Australia, not Border Force or Home Affairs department bureaucrats.
Since its revival in 2013, there have been twelve deaths in either Manus Island or Nauru. Mr Ryan said all deaths in offshore detention should be investigated by an independent judicial process similar to that for Mr Khazaei.
Amnesty International's refugee researcher, Kate Schuetze, said Mr Khazaei's death is the most thoroughly investigated of Australia's offshore detention deaths, largely because Mr Khazaei died in Brisbane, so his death fell under the Queensland coroner's jurisdiction.
"Many of the cases that have happened, the other deaths that have happened on Manus on Nauru … there hasn't been the same level of justice or accountability," said Ms Schuetze.
Looking to the future, Mr Ryan said further deaths in offshore detention would be prevented by moving to a place where healthcare standards are higher, such as Australia or New Zealand.
"However, I acknowledge such an approach is highly unlikely in the absence of a fundamental revision of the broader policy framework," he said.
The United States has agreed to take up to 1,250 refugees from Manus or Nauru, but only a few hundred have been resettled so far.
New Zealand has offered to take 150, but that's been rejected by Australia. Canberra is adamant none of the refugees will resettle there, but no one else has offered to take them.
And the situation on Manus Island itself has changed since 2014, too. The detention centre has now closed, and the refugees have been forced into what are called 'transit centres' in the main town, Lorengau.
The health provider, IHMS, no longer provides treatment, and the responsibility has been transferred to Pacific International Hospital in Port Moresby.
"We have people currently languishing in a very dangerous situation when it comes to their healthcare," said Ms Schuetze. "Those steps have to take place by the Australian government for these recommendations."
"If the Australian government cannot provide a comparable level of medical care, they really need to end offshore processing and bring those people here as a means of preventing further deaths," she said.
In a statement, IHMS said it would "consider and respond" to the coroner's recommendations.
The Department of Home Affairs said it was reviewing the coroner's findings.