If asylum seeker Hamid Kehazaei had been moved to a better-equipped intensive care unit just 10 metres away from his hospital bed he would have been likely to have survived rather than died, a doctor called upon to treat him has told an inquest into his death.
A series of “little disasters” led to the “major disaster” of Kehazaei having a cardiac arrest, anaesthetist Dr Richard Glied said.
Kehazaei, a 24-year-old Iranian asylum seeker at the Manus Island detention centre, contracted a treatable infection in his leg that deteriorated to a sepsis that caused him to suffer a series of cardiac arrests, and, ultimately, multiple organ failure.
The inquest in Brisbane heard that Kehazaei was flown to the Pacific International hospital in Port Moresby, Papua New Guinea, at about 5pm on the evening of 26 August 2014 but his condition deteriorated dramatically after admission, in part because the ventilator that was assisting him to breathe was not working properly.
In an extraordinary intervention, an International SOS specialist emergency medical team – in Port Moresby to treat Australian federal police officers, not asylum seekers – was called to the hospital to care for Kehazaei at about 10pm, five hours after he had been admitted.
Glied, who was the anaesthetist with that team, said when they arrived they found Kehazaei already perilously ill.
Glied said it was not one error, but a cascading litany of mistakes that led to his cardiac arrests and subsequent multi-organ failure – including Kehazaei being misdiagnosed as suffering a pulmonary oedema; his ventilator not working; his being fitted with child- instead of adult-sized 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.”
The AFP emergency medical team Glied was contracted to had, on permanent hire, two rooms in the Pacific International hospital for its own intensive care unit, stocked with Australian-provided equipment, technology and medicines.
Glied said if the “AFP team” had been called earlier, and Kehazaei moved to their ICU, he could have survived. The AFP ICU was “10 metres maximum, in the same corridor” from the room where Kehazaei was taken.
“I can imagine that we would have been able to avoid, that we would have had a good chance to avoid, this medical disaster.
“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.”
The Pacific International hospital has declined to cooperate with the coronial investigation into Kehazaei’s deaths.
But doctors from the hospital, in correspondence revealed before the coroner, alleged it was International SOS’s “AFP team” who were responsible for the flaws in Kehazaei’s care, by interrupting his ventilation and interfering in his care.
Kehazaei was responsive and had a central pulse, albeit weak, when he was first admitted to PIH. However, he suffered up to three cardiac arrests overnight on 26 August at the hospital, before being stabilised through resuscitation.
On the morning of 27 August, he was unconscious, scoring three out of 15 on the Glasgow coma scale, the lowest possible result.
“The patient was totally nonreactive … even to severe pain and both pupils were fixed and dilated – not even reacting to any strong light, which is a very deep reflex,” Glied said. “The patient showed early signs of the development of brain death.”
Glied and the country medical director for International SOS, Dr Kalesh Seevnarain, spoke early on 27 August about Kehazaei’s prognosis.
“At handover Dr Glied and Dr Seevnarain discussed the patient’s condition and decided that if the patient went into cardiac arrest he would not be resuscitated as they were of the view that he was neurologically dead,” the coroner heard in evidence. Kehazaei was medevaced to Brisbane on 27 August, but never regained consciousness, and died a week later.
The inquest, before Queensland state coroner Terry Ryan, continues.
