On 21 December 2016, Mr Ishak Ahmed told nursing staff he was experiencing shortness of breath and chest pains.
“It was noted that he had been attending the clinic with increased frequency lately and had become argumentative with staff,” special counsel assisting Rhiannon Helsen told coroner Terry Ryan.
Medical staff thought the recent complaints were “likely somatic in nature, or a manifestation of anxiety having excluded any other cause through a wide array of testing”.
On arguing he had a serious ailment, Mr Ishak Ahmed was encouraged to book in for a mental health follow up.
But at 10:17pm the following day, he was found unconscious at the bottom of stairs in a secure voluntary respite support accommodation area.
CCTV footage shows he appeared to lose consciousness shortly before falling backwards down the stairs.
Mr Ishak Ahmed was taken to the medical clinic in a critical condition, having suffered a life-threatening head injury.
The process for him to be urgently evacuated to Australia began at 11:40pm and culminated in his transfer at 2:15pm on 23 December.
On admission to the Royal Brisbane Women’s Hospital in the early hours of Christmas Eve, Mr Ishak Ahmed was found to have severe neurological impairments and evidence of multi-organ failure.
His injury wasn’t survivable and the refugee passed away about 1pm.
An autopsy found he sustained a traumatic brain injury from the fall and was suffering from acute pneumonia and multi-organ failure secondary to the head injury.
But signs of sickle cell disease led a pathologist to recommend experts assess whether the treatment Mr Ishak Ahmed received in the years before his death was adequate.
Certain health services were provided at the time by International Health and Medical Service (IHMS), a company contracted by the Commonwealth.
Ms Helsen said the inquest will consider Mr Ishak Ahmed’s medical care and treatment on Manus Island, including after the fall until his medical evacuation.
Mr Ryan will also look at policies and procedures relating to medical evacuations and whether there was an avoidable delay in bringing the refugee to Australia.
The steps taken by the International Health and Medical Services and Department of Home Affairs to prevent a similar death from occurring will also be considered.
Ms Helsen said a host of records and statements from IHMS, the hospital and the Home Affairs Department were still outstanding.
A further pre-inquest conference will be held on 18 May, ahead of the inquest likely to be in July or August.
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