Doctors faced “political pressure” from Australia not to bring critically-ill asylum seekers from Papua New Guinea, despite knowledge the healthcare in PNG was inferior and inadequate, an inquest into the death of an asylum seeker has heard.

The inquest into the death of Iranian asylum seeker Hamid Kehazaei – who died following a treatable infection contracted on Manus island in 2014 – was told of a “quite challenging” relationship between the doctors responsible for the care of asylum seekers detained on the island, and the Australian Department of Immigration and Border Protection which resisted medical movements for budgetary and political reasons.

“The policy was to provide medical care as much as possible to people in these situations, to provide first-world care, but there was a pressure regarding finances and budgets of doing air ambulance evacuations quite regularly at times, and for people to travel to Australia we knew that there was a political pressure in the department,” said Dr Stewart Condon, a coordinating doctor with International SOS who requested Kehazaei’s medical evacuation.

Critically ill from a leg infection that had developed into sepsis, Kehazaei was flown by air ambulance from Manus Island to Port Moresby’s Pacific International hospital on 26 August 2014, despite doctors being unanimous in their opinion that he should be brought to Australia for treatment.

Kehazaei, who had at that point been in care on Manus Island for more than 60 hours, had a persistent fever, low blood pressure, a rapid heartbeat and rapid breathing rate. He was not responding to a host of antibiotics and pain relief, could not sit up unaided, and could not walk to the toilet. He had cellulitis, abscesses, and unburst blisters on his legs, and a hard swelling in his groin.

“Sounds like he’s septic, really, doesn’t he,” Condon said in discussion with Kehazaei’s treating doctor on the island.

Condon, working from Sydney on 26 August 2014, said he had recommended that morning that Kehazaei required an urgent medical evacuation to Australia. International SOS was contracted by International Health and Medical Services (IHMS), the offshore detention’s medical provider, to coordinate medical transfers.

“I made the recommendation that he travel to Brisbane as a centre for medical excellence,” Condon said.

However, as a secondary option, Condon’s recommendation said Kehazaei could be moved to Port Moresby’s Pacific International hospital. Despite this, he told the inquest in a formal statement that because of Kehazaei’s critical situation: “Port Moresby was no longer medically appropriate.”

Asked by counsel assisting the inquest why he offered a “secondary” medical option when he didn’t believe that option could provide adequate care, Condon said there was a pressure not to move asylum seekers to Australia.

The policy not to move sick or injured asylum seekers off Manus Island was codified in the medical evacuation response plan his organisation worked by.

In a section marked “transferees”, that is, asylum seekers and refugees in offshore detention, it read:

“For transferees consideration should be given to the possibility of treatment for PNG. Recommendations for transportation to Australia can be made only once local options have been exhausted.”

Taken to Port Moresby’s Pacific International hospital on the afternoon of 26 August, Kehazaei suffered three heart attacks there, before he was moved, unconscious, to Brisbane the next day. He died a week later in Brisbane’s Mater hospital, without ever regaining consciousness.

The Australian government has consistently maintained that asylum seekers and refugees in offshore detention receive medical care “broadly comparable” with that available in Australia.

But Condon said it was known that the level of care available in Port Moresby’s Pacific International hospital was inferior to that in Australia.

“We knew with this body of information that PIH had limited facilities in terms of their emergency care, the intensive care unit, and in the skill sets of the doctors working there,” he told the inquest.

“People had told me the level of hygiene was poor, the level of staff cover was limited, and, as a hospital, while it could do some things reasonably well, it certainly wasn’t a level of care we were happy with. It was not something that we would recommend.”

Condon said the department responded to his recommendation to move Kehazaei to Australia by opting, instead to send him to Port Moresby.

“I was surprised because we had sent the updated recommendation, they were acting on old information as to how Hamid could travel off Manus Island.

“They took the option that offered quite a basic level of care, not the one that could manage his situation appropriately.”

Condon said that the medical team of International SOS always sought to prioritise patients’ medical care, but that there was “pressure” put on the operations side of the company by the government to reduce costs.

“There was an understanding that an air ambulance, for example, coming from some of these locations, would cost $100,000, and that the client was concerned at the continuing cost of that.”

Asked who “the client” was, Condon replied: “The Department of Immigration and Border Protection.”

Condon said there were regularly delays in transporting seriously- and critically-ill patients from the offshore detention centres on Manus Island and Nauru.

“There are cases where we made urgent recommendations for an air ambulance where we expected it to be happening within hours, and we waited days for approval.”

Asked by the coroner how he would categorise Hamid Kehazaei’s circumstance, Condon answered: “That was an emergency. His blood pressure and his numbers, the observations in my notes, they are critical numbers. If those numbers are seen in any of the emergency department I work in, medical teams, nurses, respond very quickly, try to fluid resuscitate people. That was an emergency.”

Doctors on Manus Island first recommended Kehazaei be urgently transferred off the island on the morning of 25 August, a full 36 hours before he was ultimately moved.

Kehazaei first presented to the medical clinic within the Manus Island detention centre at about 5.30pm on the evening of 23 August. Doctors reported he was shivering, with his hands held inside his shirt, and complaining of a fever, chills, body aches, a runny nose and sore throat. He had been unwell for two days, he said.

Condon’s evidence to the coronial inquiry, before coroner Terry Ryan, continues in Brisbane.