ARTICLE ORIGINALLY PUBLISHED IN AUSTRALIANDOCTOR. BY SARA TOWNEND 22ND AUGUST 2018
The Queensland coroner’s report into Hamid Khazaei’s death makes devastating reading.
The testimony laid out by doctors and bureaucrats explains how over a few days a tropical infection turned a healthy young man into a corpse.
Based on their evidence, the coroner concludes his death was both unnecessary and preventable.
It’s always challenging to read about medical error and its consequences for patients.
Among many things, the inquest acts as a timely warning that sepsis has an insidious onset in a young person, and causes significant morbidity and mortality — whether that is on Manus Island or in metropolitan Australia.
So it could be tempting to read Hamid’s story and think his demise understandable, given he was in a detention camp on a remote island in the Pacific where medical transfers are difficult to arrange.
But Hamid’s case is virtually unique in one sense. It provides one of only a few official, independent, in-depth insights into how healthcare delivery happens in Australia’s off-shore detention centre system.
The coroner’s report runs to 120 pages and it clearly sets out that healthcare for asylum seekers held off-shore is Australia’s responsibility.
The contractual agreement between the company chosen by the Australian Government to provide that healthcare states that the detainee should expect healthcare on Manus “broadly comparable to that available in Australia”.
While many would say that was aspirational, given the cost of sustaining such a service, it is achievable.
A group of about 70 Australian Federal Police officers have been serving in Port Moresby since 2014.
To compensate for the lack of consistent health services, the Department of Foreign Affairs and Trade has funded a full GP clinic, as well as an anaesthetist, surgeon and paramedics on call, together with permanently reserving four ICU beds in the peak private hospital.
There is some cruel irony in the fact that when the treatment was falling apart while Hamid was in the main hospital in Port Moresby, it was this team that was finally brought in as part of a last-ditch attempt to save his life.
The coroner conducted a forensic examination of the process for arranging Hamid’s transfer off Manus Island.
It ran something like this:
First, a senior medical officer doctor assessed Hamid as requiring care not available on Manus.
He sent a request to International Health and Medical Services (IHMS) in Sydney. This request passed through at least three sets of hands and two rewrites before being sent to Department of Immigration officials in Canberra where it stalled for some time before finally being approved by a senior civil servant 24 hours after the request had been made.
And this was a very straightforward request, as Hamid was stable enough to travel on the commercial flight leaving on the same afternoon.
Evidence shows that IHMS considered requesting Australia as a destination for treatment, but their experience suggested it would delay approval.
An email from the Department of Immigration and Border Protection tendered at the inquest made it clear that a transfer to Australia was “a last resort” that demanded all other local options had to be considered first.
To me as a doctor the bureaucratic resistance and delays in approving a simply transfer — particularly to Australia — is the most disturbing aspect of Hamid’s care.
Surely once a treating doctor had made a clinical decision about the care required by the patient and a decision about the need for a clinical transfer, then the bureaucratic involvement should go no further than the logistics of securing the transfer requested?
A key component of a coroner’s findings is to make recommendations designed to prevent further deaths. And in this case there is a demand for bureaucratic efficiency, for the system of transfer requests to become simple.
Of course, Manus Island’s detention centre is closed now.
But all the main players who were meant to protect Hamid’s welfare — the immigration department, IHMS and International SOS — told the inquest about their commitment to reform.
And they also paid lip service to the idea that clinical decisions should be made by clinicians, not bureaucrats.
So lessons have been learnt? Is the system fixed? Will there be no repeat?
It is worth asking what currently happens on Nauru because the process of requesting transfer off Nauru is more convoluted.
There, the population held in detention is divided into two groups. For asylum-seekers, the process of referral off-shore mirrors that of Manus: a medical officer sees a patient and contacts IHMS in Sydney.
They draft a request to Canberra, then they wait to see if it is approved.
For actual refugees, medical care has been deputised to the Nauruan health system.
IHMS staffs a basic clinic, but IHMS doctors are required to refer to a Nauruan doctor for any specialist care.
It is reported to take 4-6 referrals before such requests are even acknowledged. Reports about the hospital suggest its level of care is “variable” at best. The word “variable” is a euphemism to most doctors.
If a refugee needs care not available on the island, a further referral is made by IHMS to the Overseas Medical Review committee, which meets irregularly. Nor does it communicate or routinely minute its findings. If this committee agrees, the request is then passed to the Australian Border Force for assessment.
Earlier this year, an internal communication from IHMS was leaked to the Guardian.
It was written by an IHMS doctor who stated that the Australian Border Force was putting “extreme limitations on the types of patients” that can be referred off-shore.
“[This] does not stop us requesting these transfers but, as we are not in control of that aspect of things, the patients are entirely at the mercy of the decisions made by ABF as regards transfers," the doctor’s communication continued.
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Doctors on Nauru who have navigated this system have also spoken out in frustration at the delays and challenges of having to rely on the under-resourced Nauruan system.
Dr Nick Martin, who was a senior medical officer on Nauru between November 2016 and August 2017, was involved in a social media exchange this year with the former ABF commissioner Roman Quaedvlieg.
He claimed that every medical transfer request he made to get patients the treatment they needed was blocked.
The stubborn practice of blocking such requests has also been evident in a number of Federal Court cases this year that have overturned government refusals of clinical requests for transfer.
The patients at the centre of these cases have included a six-month-old with suspected encephalitis, a 10-year-old attempting suicide and a middle-aged woman with a blocked coronary artery requiring stent.
The death of Hamid was tragic in the true meaning of that overused word: the death was unnecessary and it could have been avoided.
All of those organisations involved have given their responses and made commitments to ensure there will be no repeat.
But there is a growing body of evidence that, despite the government’s assertions, decisions about the treatment and care of refugees and asylum-seekers are still not being made purely on the basis of the medical needs identified by doctors.
It’s only a matter of time before another email stalls long enough in the bloated transfer process to cause another death. No doubt, like Hamid’s death, it will also be judged preventable.