When Faysal Ishak Ahmed collapsed on stairs at the Manus Island detention centre in Papua New Guinea, his jaw locked due to a seizure and he died by the time he was airlifted to Brisbane.
A Brisbane inquest into the Sudanese refugee's death in 2016 has heard his medical transfer to Australia became a bureaucratic exercise and a neurosurgeon was not contacted for at least five hours after his fall.
Mr Ahmed, an asylum-seeker who fled conflict in Sudan in 2013, was detained by the Australian government in the now-shuttered offshore detention centre for three years.
The 27-year-old presented to International Health Medical Services staff about 60 times during his stint with complaints of jaundice, gastric symptoms, kidney pain, chronic sinusitis, mental health issues and chest pain.
He saw medical staff eight times alone in December 2016 - the month he died.
IHMS was the Australian government contracted healthcare provider at the centre until 2018. Its lawyers were also present at the inquest on Monday.
State Coroner Terry Ryan is examining circumstances surrounding Mr Ahmed's death and the standard of his treatment throughout 2016 as his health worsened.
Two expert witnesses, rural GP Anthony Brown and clinical toxicologist Mark Little, who prepared coronial reports into Mr Ahmed's death at the time, gave evidence on Monday.
Counsel Assisting Sarah Lane asked Dr Little whether the death could have been averted if more investigations had been carried out
"That's really difficult to say... I believe this man had a seizure - it was his fall and his head strike that resulted in his death," Dr Little said.
"The cause of his seizure was due to low sodium levels ... but as to the cause of the low sodium, I'm unclear."
Dr Little described the confronting CCTV footage he reviewed of Mr Ahmed's collapse to arrive at his findings.
"He seemed vague or distant. He was pacing. He seemed a bit unsteady on his feet and then when he gets to the stairs, he doesn't trip, he literally drops and doesn't protect himself at all."
Dr Little said low sodium was a "very difficult diagnosis".
"It's a very non-specific finding. To be fair to the clinicians in Manus Island, they had done these urea-electrolyte tests which were all normal," Dr Little said.
"I don't think I would have picked it prior to him falling."
Dr Little also noted remote locations were not equipped to deal with complex medical cases.
"It's late at night, you're in a remote location, you have a man with a severe head injury so I thought it (the medical treatment) was reasonable," he said.
"If this man was in one of our rural hospitals (in Queensland), I don't think he would have survived that injury."
But he criticised the delayed bureaucratic response in medically evacuating Mr Ahmed to Brisbane.
"It seemed like a lot of people were involved to make this transfer," Dr Little said.
"I wondered if a lot of the organisational work could have been simplified for the transfer... at least be organised and set in a quicker period of time."
Dr Little also took issue with why certain procedures such as consulting a neurosurgeon were not readily in place.
"Manus Island has been running for years and again I would have thought that disposition planning, if there was a crisis or medical or surgical emergency on this remote location, would have been predetermined," he said.
Dr Brown also found it puzzling medical staff did not seek a neurosurgeon for advice for five hours after Mr Ahmed's fall.
"I was unsure why they didn't talk to the neurosurgeon for five hours. That wasn't explained," Dr Brown said.
The inquest is one of a handful in recent years that delves into the medical care provided to people detained offshore by the Australian government.
The inquest continues on Tuesday.
