The death of Iranian asylum seeker Hamid Khazaei was preventable and the result of “compounding errors” in health care provided under Australia’s offshore immigration detention system, the Queensland coroner has found.

Coroner Terry Ryan found 24-year-old Mr Khazaei, who died in a Brisbane hospital in September 2014 after he contracted a leg infection in Manus Island detention centre, would have survived had his rapid deterioration been recognised.

Mr Khazaei suffered severe sepsis from a leg infection and was first moved to Port Moresby before being flown to Brisbane, where nothing could be done to save his life.

Mr Ryan found the failures included not clearing Mr Khazaei for a timely medical transfer to a Port Moresby hospital from Manus Island, where the level of health care was “not commensurate with a clinic in remote Cape York”.

He found the Department of Home Affairs needed to enforce new policy that put the clinical needs of detainees first when medical transfers required the approval of Australian immigration officials.

Mr Ryan also called on the Federal Attorney-General to establish a new framework ensuring independent judicial investigations of deaths in Australia’s offshore detention system.

Mr Khazaei was pronounced brain dead at Brisbane’s Mater Hospital after a worsening systemic infection caused cardiac arrests at the Pacific International Hospital in Port Moresby.

The dental section of Lorengau Hospital on Manus Island. Photo: AAP

Mr Ryan said his death occurred in the context of Australia’s policy of deterring asylum seeker arrivals by boat through offshore detention and highlighted the practical problems of ensuring adequate health care in remote tropical locations such as Manus Island.

“It would be possible to prevent further deaths by relocating asylum seekers to other places like Australia and New Zealand,” he said.

But Mr Ryan acknowledged this was “highly unlikely” without a substantial revision of Australia’s detention policy.

In handing down his findings, Mr Ryan said it was possible to characterise the circumstances that led to Mr Khazaei’s death “simply as a series of clinical errors”.

But he said attributing these mistakes “solely to individual clinicians is not helpful to prevent similar incidents in the future”.

A Department of Home Affairs spokesperson said it was reviewing the coroner’s findings.

“The department has provided full assistance to the inquiry,” the spokesperson said.

“The department expresses our condolences to the family and friends of Mr Khazaei.”

‘Most awful colour I’d ever seen in a human being’

During the inquest hearings, Dr Marten Muis told the court he had just arrived to work on the island when he was told to organise an urgent evacuation of Mr Khazaei to a Port Moresby hospital.

Dr Muis said as the medical team was making flight preparations, he rang his International Health and Medical Services colleagues as he had not heard if the flight had been confirmed.

Dr Muis told the hearing he was told “it’s not happening because we haven’t obtained a visa”.

He said he was told people in detention in Papua New Guinea needed a visa to leave Manus Island.

“It was really all double Dutch to me,” Dr Muis said.

He said he was told there were no other options to get Mr Khazaei off the island until the following day as there were no medical evacuations at night.

Dr Muis said he was told, “I’m very sorry but you’re on your own and you’ll have to keep this man overnight”.

When asked what his response was, Mr Muis said, “What can you do?”.

Dr Muis said when he arrived at the clinic the next day, Mr Khazaei had rapidly deteriorated and looked completely different.

“He was the most awful colour I’d ever seen in a human being,” Dr Muis said.

“He was just grey, blue.”

-ABC