Key findings in Khazaei refugee death

CORONER TERRY RYAN'S KEY FINDINGS AND RECOMMENDATIONS ABOUT HAMID KHAZAEI'S DEATH

HOW AND WHY HE DIED

* Mr Khazaei died from complications arising from a leg infection he contracted on Manus Island

* His death was preventable and a result of multiple errors

* His treatment at the Manus Island clinic and the Pacific International Hospital in Port Moresby was inadequate

* Medical staff failed to report he was severely deteriorating

* The transfer process from Manus Island was ineffective

KEY RECOMMENDATIONS

1. The federal government develop a policy for medical transfers that gives overriding consideration to the welfare of detainees

2. Development of a patient treatment checklist to support timely transfer requests

3. Offshore health care facilities be accredited to Australian health service standards

4. The federal government and Royal Australian College of General Practitioners conduct annual audits of offshore medical clinics

5. The federal government establish critical care units near detention centres

6. Mandatory inquests for asylum seekers who died in offshore centres.