Deaths inside Australia’s onshore and offshore immigration detention regimes will be examined by coroners on opposite sides of the country this week.
On Monday in Queensland the state coroner Terry Ryan will deliver his findings from the inquest into the 2014 death of 24-year-old Iranian asylum seeker Hamid Kehazaei, who died after a routine infection, contracted inside Papua New Guinea’s Manus Island detention centre, was inadequately treated, developing into sepsis and ultimately, a series of catastrophic heart attacks and multiple organ failure.
On the same day in Perth, the coroner Sarah Linton will begin a two-week inquest into the 2015 death of Fazel Chegeni Nejad, who died on Christmas Island after escaping from the detention centre there.
Nejad’s case workers from within the then immigration department – now the Department of Home Affairs – had repeatedly pleaded with superiors in the government to release him from detention and adequately treat his mental and physical health issues.
Kehazaei, whose name is more accurately translated Khazaei but whose Australian government documents list the former spelling, died in a Brisbane hospital in September 2014 after his life-support machine was turned off when doctors saw there was no prospect of his survival.
The inquest into his death, held over two separate weeks in 2016 and 2017, heard damning evidence about bureaucratic delays and cascading failures in his care.
Doctors who treated him on Manus Island told the coroner that Kehazaei had initially presented with a small, apparently routine, infection in his leg. But when he did not respond to antibiotic treatment and his condition precipitously deteriorated, doctors repeatedly requested he be urgently transferred to Australia for hospital-level care.
The coroner heard that, after being briefed by phone on Kehazaei’s failing health, the department of immigration’s assistant director of detention health services, Caroline Gow, emailed her superior director, Amanda Little, saying Kehazaei had “exhausted all antibiotic treatment that is available on Manus Island” and needed an “urgent medical transfer”.
After a delay of more than five hours – Little told the coroner she did not check her emails in that time – she responded, refusing to “escalate” the transfer request and asking why he could not be treated on the island.
After another email stressing the serious nature of Kehazaei’s condition, the original request was escalated, but that email was not read by the assistant secretary Paul Windsor for a further 13 hours.
It was a further 17 hours before Kehazaei was finally moved, not to Australia where doctors had recommended, but to Port Moresby’s Pacific International hospital, where he was misdiagnosed, treated with broken equipment and left unattended as he grew critically ill.
Dr Richard Glied, an anaesthetist with an International SOS specialist emergency medical team – in Port Moresby to treat Australian federal police officers – was then called in to treat Kehazaei. He painted a damning picture of the care he had received.
Glied told the coroner not one error, but cascading mistakes had led to Kehazaei suffering multiple cardiac arrests and subsequent multi-organ failure – including his being misdiagnosed as suffering a pulmonary oedema; his ventilator not working; his being fitted with child-sized instead of adult intravenous cannulae; and his being left unattended even as the machines keeping him alive were “alarming”.
“My problem is when you have a strong man, a young man who did not have any past relevant medical history, who did not have a cardiac problem, no disability, who was just a few days before a healthy strong man, then it needs a lot of little disasters, following one after the other, none of them caught up and resolved, for it to finally to end up in a major disaster.”
Glied said if the “AFP team” had been called earlier, and Kehazaei moved to their intensive care unit, he could have survived. The AFP ICU was “10 metres maximum, in the same corridor” from the room where Kehazaei was taken.
“For sure, we would have been able to stabilise this patient, and I’m sure we would have been able to avoid the cardiac arrest before transferring this patient to Brisbane.”
Glied said despite Kehazaei being clearly critically ill from the moment he was admitted to Pacific International hospital, he was left unattended for significant periods of time. “They [the PIH] had good doctors who had the knowledge, but they were not present. And you cannot treat this patient on the phone.
“I cannot understand why they left that patient with the nightshift doctor, who has to deal with the emergency department, and the ward patients.”
Nejad – more often known as Fazel Chegeni – died on Christmas Island in November 2015 after escaping from the island’s detention centre. A stateless Kurd who had been repeatedly tortured in Iran – including being beaten, raped and dumped in the desert to die – he was facing indefinite detention within Australia’s regime.
The inquest is expected to focus on his behaviour and psychological state in the lead-up to his disappearance and death, and his treatment by the Australian government.
His immigration department file of more than 700 pages was leaked to the Guardian in 2015, revealing that, over years, doctors, psychiatrists and department officials warned on more than a dozen occasions that Chegeni’s mental health was being harmed by his ongoing detention, highlighting his history of torture and trauma in Iran, his repeated suicide attempts, and stating he should be released from detention.
“He is obviously becoming very exhausted by the prolonged period of detention and I would support a new place for him, this may help improve his mental well-being,” one of his final case notes says. Also mentioned was Chegeni’s “past history of attempted hanging”.
But Chegeni faced being detained for the rest of his life. Iran would not accept his forcible return and he had been convicted after an encounter inside Curtin detention centre when he was abused and assaulted by, and then fought with, another detainee. On appeal, a judge threw out his sentence, but because he had received poor legal advice and pleaded guilty, his conviction stood. He was therefore deemed to have failed the Migration Act’s “character test” and faced an indefinite detention.
Chegeni’s body was found two days after he escaped from the Christmas Island detention centre in rugged bushland. He was 34.
• In Australia, the crisis support service Lifeline is on 13 11 14. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In the UK, the Samaritans can be contacted on 116 123. Hotlines in other countries can be found here
