The letters, in the last months of Faysal Ishak Ahmed’s life, became frantic.
“I collapsed down from heart problem,” he wrote in October 2016, “and numb on my arms, hands and finger as well.
“I came to IHMS [International Health and Medical Services] more than 20 times but till now I don’t know my problem,” a December note, in faltering hand, reads.
Ishak Ahmed’s pleas were met, consistently, with dry bureaucratic response: “Thank you for your correspondence outlining a medical issue …”
Doctors on the island believed his condition was “likely somatic in nature, or a manifestation of anxiety”, but the Sudanese refugee, detained on Manus Island for three years within Australia’s offshore processing system, insisted he was gravely ill.
“I am not pretending,” he reportedly told friends the day before he died. “I cannot breathe, my heart is not working.”
In 2016, the last year of his life, Ishak Ahmed presented to the doctors within the Manus Island detention centre 60 times. In December alone, he presented eight times. He would be dead before the month was over.
Others saw his deterioration too. The day before the sudden collapse that would ultimately kill him, dozens of fellow refugees signed a letter begging for help for Ishak Ahmed, “before it is too late”.
As the coronial inquest into Ishak Ahmed’s death began in Queensland this week, it was said outside court by a refugee advocate that the compounding tragedy of his death was that he should never have been on Manus Island.
Australia’s detention regime there was illegal. In April of 2016, eight months before Ishak Ahmed died, Papua New Guinea’s supreme court ruled that Australia’s system of punitive detention was unconstitutional and ordered that the centre be shut.
It endured beyond. Long enough for Ishak Ahmed to die.
Searching for safety
Ishak Ahmed arrived in Australia by boat in September 2013, having fled the chaotic violence of his native Sudan.
In his application for protection, he told Australian authorities how the Janjaweed militia had attacked his village, killing 35 people, including his brother and grandmother.
He fled to a displaced persons camp, but found he was still not safe.
“On many occasions the Janjaweed militia entered the camp and killed people,” his file records. “I was handcuffed and tied to a tree for two or three days. I was beaten badly. I have … scars on my forehead where I was whipped.
“The militia wanted me to join them as a fighter but I refused.”
Australia, he hoped, held the promise of safety.
Having arrived at Christmas Island, within weeks he was exiled to Manus Island, arriving on 9 October 2013. Others sent with him remember being told they would be there “only a short time” before being resettled.
But as one year became two, became three, Ishak Ahmed’s health faltered and then collapsed. He became increasingly despondent. He confided in fellow refugees he had left behind a wife and young son.
“If anything happens to me, I need you guys to look after my family,” he told them.
Alone when he falls
Ishak Ahmed’s presentations to the Manus Island clinic had become increasingly fractious.
His inquest heard medical staff had run numerous tests on his wide array of symptoms without establishing a definitive diagnosis.
His final visit with a doctor was on 21 December 2016.
Fellow refugees say he returned from that appointment distressed, saying he had been told there was nothing wrong with him, and he would not be seen again.
He insisted, fellow refugees say, he was dangerously unwell. “This disease will kill me,” they remember him saying.
CCTV footage before the coroner shows Ishak Ahmed the next night, shortly after 10pm, in a compound known as the voluntary respite support accommodation area.
Ishak Ahmed is seen walking back and forth, before he clutches his chest and staggers, and then falls backwards down a one-metre flight of stairs.
His head hits the concrete platform at the bottom. He is alone when he falls.
Security guards rush to his aid. He will never regain consciousness.
The room where deaths are reckoned with
Court four in the Brisbane magistrates court is cool and serene, far from the heat and the isolation of Australia’s Manus Island detention centre, far from the madding chaos of injury and illness.
This is the room where offshore deaths keep coming. This is the room where they are reckoned with.
Here, before the state coroner Terry Ryan, it was heard how Hamid Kehazaei died from medical neglect on Manus Island in 2014, a treatable infection that was misdiagnosed then maltreated and his transfer to hospital delayed.
Kehazaei could have been saved by basic interventions at several points during his worsening illness, Ryan found, but that “the compounding effect of multiple errors” and “systemic failures” in the offshore healthcare system caused him to die.
Omid Masoumali’s inquest came here too, before the same coroner. Masoumali, 24, doused himself in petrol and set himself alight on Nauru in 2016, in protest at the sclerotic pace of refugee processing. It was more than 30 hours before he was flown to a Brisbane hospital: had he been moved more swiftly, he had a 95% chance at survival, his inquest heard.
This inquest into Ishak Ahmed’s death is particularly limited. Government and health contractors successfully sought to narrow the focus of the inquest to the particular circumstances of his death, rather than examining systemic factors of his detention.
There are hints of this in the testimony. The medical evidence is consistently caveated: “as far as could be done on a remote island” … “using the tools at hand you would have in a remote healthcare environment” … “in the context of Manus Island”.
The implication is even heard expressly: “if this were in my hospital …”
But the broader question, the appropriateness of sending someone to a place where it is known they cannot receive adequate care – and of leaving them there when their health collapses and their sickness persists – is outside the scope of this inquest.
This is the yawning silence left unanswered.
In public evidence, this inquest did not hear from anybody who was on Manus Island at the time of Ishak Ahmed’s death, nor from anybody who had ever treated him or even who knew him. Those detained alongside him were not called to appear before the coroner.
The expert doctors who consulted Ishak Ahmed’s file said his care on the island was generally sound for the setting, but were critical that his hemolytic anaemia – a blood disorder – went undiagnosed for five months before he died. When his symptoms of jaundice temporarily cleared up, the reason for his recurrent illness “was never pursued”.
There was dispute over what caused Ishak Ahmed to suddenly fall backwards down the stairs: some doctors opined hyponatraemia – low blood sodium – sparked a seizure, others argued a cardiac arrhythmia caused by undiagnosed sickle cell trait made him lose consciousness. It could not have been known by doctors that he would fall when he did, the inquest heard.
But there was some unanimity: from the moment Ishak Ahmed’s head hit the concrete at the foot of the stairs, his prognosis was poor.
His head injury was catastrophic, and the 30-year-old (the Australian government said he was 27, but his immigration file has his birthdate wrong) never regained consciousness.
Despite the obvious injury, there was a delay of five hours before a neurosurgeon was called for specialist advice.
And it took more than 26 hours – with delays up and down the bureaucratic chain in Australia and PNG to find and cost a medical evacuation flight – before Ishak Ahmed was moved from the rudimentary Manus clinic to a tertiary hospital in Brisbane.
There can, of course, never be the counterfactual with which to compare: but even had those things been done differently, those delays erased, it is likely Ishak Ahmed could not have been saved once he fell, the inquest heard. An autopsy found Ishak Ahmed was suffering from “acute pneumonia and multi-organ failure secondary to his head injury”.
What changes?
State coroner for more than a decade, Terry Ryan has previously been excoriating about the structural failures of Australia’s offshore detention system.
He has reported before on deaths that were the “result of the compounding effects of multiple errors”, and noted “it would be possible to prevent similar deaths by relocating asylum seekers to other places, such as Australia or New Zealand, where better healthcare would be provided”.
But little changes.
Manus is closed now. By PNG’s supreme court, not the Australian government, and 52 refugees and asylum seekers remain stranded in that country – still without a permanent place anywhere, after more than a decade held offshore.
And Nauru continues as Australia’s sole “enduring” form of offshore processing, of deterrence, of collective punishment as example to others who might risk a leaky boat for a chance at a new life.
The architecture of offshore processing remains.
The idea, too, remains as entrenched as ever, and now one that is being exported to new lands: the UK wants offshore processing in Rwanda; Italy and Albania have signed an agreement for the transfer of boat-borne asylum seekers out of Europe.
Alone at the end
After Ishak Ahmed’s death “the family lost all hope in life”, his brother Suliman said ahead of this week’s coronial hearings. His family wanted to be part of the inquest into his death; they wanted answers about what had happened to their son, brother, father and friend.
Translators and an online link to Khartoum had been arranged.
But such is the current unrest in Sudan – a continuation of the chaos Ishak Ahmed fled a decade ago – his family could not find a reliable internet connection or a place where they could safely observe the hearing.
It went ahead without them.
