Masoumali, Omid
Deceased
Omid Masoumali
Demographics
24y, male
Date of death
2016-04-29
Finding date
2021-11-01
Cause of death
Multiple organ failure due to or as a consequence of severe thermal burns
AI-generated summary
Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement. He was airlifted to Brisbane but died on 29 April 2016 from multiorgan failure. Critical clinical lessons include: (1) inadequate mental health triage—his self-referral for psychology on 26 April was not followed up with direct contact despite a known high-risk population; (2) resource constraints at Republic of Nauru Hospital (RNH) including obsolete ventilation (bellows anaesthetic machine rather than modern ventilator), lack of monitoring equipment, limited laboratory capacity, and inability to manage complex burns; (3) delayed recognition of abdominal compartment syndrome due to insufficient monitoring; and (4) a 31-hour evacuation delay imposed by operational constraints. While RNH staff made heroic efforts with limited resources, a patient with 50% burns would have 90-95% survival with timely specialist care. Early contact after the mental health referral might have offered intervention, though prevention cannot be assured.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- inadequate mental health triage and failure to follow up self-referral form with direct contact on 26 April 2016
- lack of specialist burns capability at Republic of Nauru Hospital
- absence of modern mechanical ventilation—use of obsolete bellows anaesthetic machine instead of modern ventilator
- inadequate monitoring equipment (no arterial lines, central venous pressure monitoring, or bladder pressure monitoring for ACS detection)
- limited laboratory capacity and unavailable blood products
- delayed recognition and treatment of abdominal compartment syndrome
- prolonged evacuation timeframe (31 hours) due to Nauru airport restrictions and crew rest requirements
- respiratory acidosis from inadequate ventilation
- cardiac arrest at RNH on 27 April 2016
Coroner's recommendations
- The Commonwealth should work with the Government of Nauru to provide clear information on timing of refugee status determination and plans for settlement to reduce mental health impact of ongoing uncertainty and expedite resettlement of successful asylum seekers to third countries, which would likely reduce mental health-related medical transfer requests
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