Coronial
QLDhospital

Khazaei, Hamid

Deceased

Hamid Khazaei

Demographics

24y, male

Date of death

2014-09-05

Finding date

2018-07-30

Cause of death

Hypoxic-ischaemic encephalopathy, due to or as a consequence of cardiac arrest, due to or as a consequence of severe sepsis, due to or as a consequence of left lower leg infection with Chromobacterium violaceum

AI-generated summary

Hamid Khazaei, an Iranian asylum seeker aged 24, died on 5 September 2014 after contracting a leg infection (Chromobacterium violaceum) on Manus Island while in immigration detention. His death was preventable and resulted from multiple compounding errors: failure to recognise severe sepsis despite worsening vital signs; lack of appropriate antibiotics at the Manus Island clinic; failure to intubate and aggressively resuscitate him before transfer; inadequate handovers and communication between clinical teams; delayed transfer approval due to bureaucratic processes; and inadequate critical care capacity at the receiving hospital in Port Moresby. If Mr Khazaei had been transferred to Australia on 25 August 2014 with proper airway management, he likely would have survived. The case highlights systemic failures in offshore detention health services and gaps between policy requirements and actual clinical care.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

emergency medicineinfectious diseasesintensive careanaesthesia

Error types

diagnosticcommunicationproceduralsystemdelay

Drugs involved

ceftriaxoneparacetamolbenzylpenicillincefalexinazithromycinerythromycinchloramphenicolflucloxacillingentamicinmidazolamibuprofenadrenalinenoradrenaline

Clinical conditions

severe sepsisseptic shockacute respiratory depressionhypoxiacellulitis with abscesschromobacterium violaceum infectionacute respiratory distress syndromemulti-organ failurerenal failurecardiac arresthypoxic ischaemic encephalopathybrain deathchronic granulomatous disease

Procedures

intubation (not performed when required)mechanical ventilationmanual ventilation with ambu-bagintravenous line insertionblood gas analysischest X-raycardiopulmonary resuscitation

Contributing factors

  • Failure to recognise clinical deterioration and severe sepsis at Manus Island clinic
  • Lack of adequate antibiotics at Manus Island clinic to treat tropical infections
  • Failure to intubate and aggressively resuscitate on Manus Island
  • Inadequate recording systems for vital signs observations
  • Flaws in transfer approval process resulting in missed afternoon flight opportunity on 25 August 2014
  • Inadequate handover from Dr K. to retrieval team on tarmac
  • Failure of retrieval team to intubate before flight
  • Lack of communication between clinical teams about severity of condition
  • Inadequate critical care capacity at Pacific International Hospital
  • Delayed intubation at Pacific International Hospital (almost 2 hours after arrival)
  • Defective equipment at Pacific International Hospital (damaged ambu-bag, malfunctioning ventilator)
  • Chronic Granulomatous Disease (CGD) as predisposing factor to infection

Coroner's recommendations

  1. The Department of Home Affairs should develop and implement a written policy for medical transfers from regional processing centres led by persons with clinical training in emergency medicine, with health and wellbeing as overriding consideration
  2. Set form/checklist should be completed by International SOS clinicians when onsite clinician requests patient transfer, including accurate clinical condition, observations from previous 4-6 hours, medication regimes, effectiveness of treatment, physical presentation, and required timeframe for transfer
  3. Clinics providing medical services to asylum seekers in regional processing countries should be accredited to Royal Australian College of General Practitioners Standards equivalent to Australian immigration detention centres
  4. Department of Home Affairs and IHMS should collaborate with RACGP to implement standard clinical audit tool at all regional processing country clinics
  5. Extended site visits should be conducted annually to observe clinical practices and physical medical consultations, including inventory audits in conjunction with RACGP
  6. Critical care units should be established in close proximity to regional processing centres, consistent with Australasian College for Emergency Medicine standards
  7. Pacific International Hospital's critical and intensive care capacity should be benchmarked against Australian standards developed by College of Intensive Care Medicine and Australasian College for Emergency Medicine
  8. Commonwealth Attorney-General should establish statutory framework to ensure independent judicial investigation of deaths of asylum seekers transferred to regional processing countries, with appropriate post-mortem examinations and amendments to contractual arrangements to ensure cooperation
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