Inquest into the Death of Hamid Khazaei

Background Facts

Hamid Khazaei was a 24 year old Iranian Citizen who entered the 'migration zone' at Christmas Island on 7 August 2013 on board a boat. On 6 September 2013, the Department of Immigration and Border Protection ('DIBP') transferred the deceased to the Manus Island Regional Processing Centre (MIRPC) in Papua New Guinea because he did not hold a valid visa to Australia. The DIBP had in place contractual arrangements with International Health and Medical Services ('IHMS') for the delivery of services, including healthcare, to the detainees on Manus Island.

The deceased became ill and presented to the IHMS clinic on 23 August 2014 with flu-like symptoms and a small lesion on his leg. He was given antibiotics 'to cover a broad spectrum of infections'. His condition rapidly deteriorated and he was eventually transferred to the Pacific International Hospital in Port Moresby (PIH). The condition of the deceased continued to deteriorate at the PIH, which at that time lacked an intensive care unit. The inquest heard that the delay in responding to the crucial needs of the deceased led him to cardiac arrest. On 27 August 2014, he was transferred by medevac to Brisbane.

A clinical examination on the morning of 28 August 2014 revealed a Glasgow Coma Score of 3 and absent brainstem reflexes consistent with a profound brain injury. No handover had been received in relation to Mr Khazaei’s clinical management at the PIH. He was declared brain dead on 2 September 2014. On 5 September 2014, Mr Khazaei was declared deceased, aged 24.

An autopsy revealed that the cause of death was hypoxic-ischaemic encephalopathy, due to the consequence of cardio-respiratory arrest, due to the consequence of left lower leg infection with chromobacterium violaceum.

The inquest into the death of Mr Khazaei investigated the adequacy and appropriateness of the medical care provided to him during his time at MIRPC, the subsequent sequence of transfers, and the adequacy and appropriateness of the policies and procedures in place.

Findings

The State Coroner Terry Ryan found that Mr Khazaei's death was preventable. The inquest concluded, in accordance with expert witness evidence, that if Mr Khazaei's clinical deterioration was recognised and responded to in a timely manner at MIRPC, and he was evacuated to Australia within 24 hours of developing severe sepsis, he would have survived.

The Coroner stated that it would be 'possible to characterise the circumstances that led to Mr Khazaei's death simply as a series of clinical errors compounded by failures in communication that led to poor handovers and significant delays in his retrieval from Manus Island'. He further noted that Mr Khazaei's death occurred in the broader context of Australia's immigration law and that he had been detained on Manus island for almost 12 months at the time of his death.

The Coroner noted that Mr Khazaei was entitled to receive the care that was 'the best available in the circumstances and broadly comparable with health services within the Australian community'. He further stated that the health care received by the deceased from PIH was not adequate. There are, according to the Coroner, 'many practical and operation issues associated with delivering the appropriate standard of health care in a remote offshore processing centre'.

The Coroner made various recommendations including that clinics that provide medical services to asylum seekers be accredited to the Australian standards.

The Coroner further recommended that the Commonwealth Attorney-General establish and fund a statutory framework for independent judicial investigation of deaths of offshore asylum seekers.

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