After he set himself fatally alight, a Iranian refugee was treated on a cot in a mouldy room in Nauru hospital surrounded by "agitated" people, an inquest has heard.
Lifeflight doctor Angus McDonell was on the team to transfer Omid Masoumali to Brisbane about a day after the refugee set fire to his petrol doused-clothes at a resettlement area on Nauru in April 2016.
When Dr McDonell arrived on the tiny Pacific island, Mr Masoumali was in an induced coma with burns to about 50 per cent of his body.
The situation around him, he testified, was volatile, the hospital unclean and equipment old or not working.
"There were a lot of people at that hospital. I suspect there were friends of Omid. I had a heightened awareness of my own safety and the safety of my colleagues," Dr McDonell told Brisbane Coroners Court on Thursday.
"There were a lot of people moving around and a lot of people clearly upset. There was a great desire for me to speak to them.
"It felt a volatile situation."
He also said Mr Masoumali, 23, had carbon dioxide levels so high he thought they were "erroneous".
"It would have been at great advantage to him to have been able to have the CO2 levels brought down ... at a much earlier stage of his treatment," the Masoumali family's barrister Shane Prince SC said.
Dr McDonell agreed, before being shown photos of Mr Masoumali being treated in the hospital prior to his arrival in what appeared to be "a baby's cot".
"That's where they treated him," Mr Prince said.
"That's obviously mould on the wall. That's obviously not ideal for a patient that is ventilated."
Mr Masoumali arrived at Royal Brisbane and Women's Hospital about 30 hours after he burned himself. He later died of organ failure.
A burns specialist who treated him at the Brisbane hospital agreed his treatment conditions on Nauru were "unacceptable".
One of the reasons Lifeflight was unable to get him to Australia earlier was because Nauru's airport runway was poorly lit, meaning travelling there at night was unsafe, the inquest heard on Thursday.
Mr Masoumali died two days after setting fire to himself in front of UN representatives who had "upset and frustrated" his partner, the inquest has heard.
He had poured petrol onto his clothes, with phone footage showing him pacing around a re-settlement area of Nauru, yelling intensely then being engulfed in a large ball of flames.
The inquest continues.
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Australian Associated Press