A Sri Lankan asylum seeker who died from a severe asthma attack just hours after arriving at the Christmas Island immigration detention centre received inadequate medical care, a WA coroner has found.
Arulselvam Velmurugu fled communal riots in Sri Lanka in November 2012 and arrived in Australia almost six months later after two boat journeys and nearly three months in a refugee camp in Sumatra, where deadly fights broke out.
The 35-year-old was treated for his asthma at a hospital in Medan, where his care was better than on Christmas Island, Coroner Barry King said in findings released on Tuesday.
While Mr Velmurugu died from natural causes, the government-appointed health care contractor International Health and Medical Services Pty Ltd did not have an appropriate triage system and lacked an effective equipment organisation and maintenance system.
There had also been a possible communication error, Mr King said.
The coroner said he was unable to find whether the failure to provide Mr Velmurugu with an adequate standard of treatment and care contributed to his death.