An Aboriginal man died on his cell floor because there was a “confused, unreasonably delayed, and uncoordinated” medical response by prison staff, a coronial inquest has found.
Warning: This story contains an image of an Indigenous person who has died.
Deputy state coroner Elizabeth Ryan handed down her findings on Thursday into the death of Anaiwan and Dunghutti man Nathan Reynolds.
The 36-year-old died on the concrete floor in his prison cell at John Moroney Correctional Facility in Berkshire Park on September 1, 2018, from bronchial asthma — one week before he was expected to be released.
Ms Ryan said on the night of Mr Reynolds’s death he required emergency treatment but the response he received “fell well short of this”.
“It was confused, uncoordinated and unreasonably delayed,” Ms Ryan said.
“The delay deprived Nathan of at least some chance of surviving his acute asthma attack.
“These failures were due both to numerous system deficiencies and to individual errors of judgment.”
But the coroner found Mr Reynolds died of “natural causes” that were partly exacerbated by deficiencies in the management of his severe asthma.
His sister Taleah Reynolds said she was furious and that her brother’s death was “preventable”.
“Several times he went to the prison clinic and said he wasn’t feeling well, it was never any secret that Nathan was asthmatic.
Ms Reynolds said her brother “would not have died [from this asthma attack] if he weren’t in prison”.
“This can’t just be treated as an accident — it must be recognised as a huge institutional failing and people must be held responsible,” she said.
The inquest heard Mr Reynolds, who was struggling to breathe, urgently called for help at 11:27pm on August 31, 2018.
But it would take prison guards about 11 minutes to respond as inmates desperately tried to help him.
An ambulance was called at 11:48pm and the registered nurse on duty arrived at the scene two minutes later.
By that time, Mr Reynolds was already unresponsive.
Mr Reynolds was declared dead by paramedics at 12:44am, about half an hour after the ambulance arrived on the scene.
Ms Ryan said the failures went beyond what happened on the night of the emergency, saying the health care he received since entering custody was “inadequate”.
“It failed to reduce his risk for a fatal asthma attack, it did not comply with established treatment for the management of severe asthma,” she said.
“These failings significantly increased Nathan’s risk for the fatal attack.”
She said Mr Reynolds’s death has exposed the need for changes to be made in the care given to people with severe asthma in NSW prisons.
Among the recommendations made to Justice Health and Corrective Services NSW were a review of its policies and procedures and the instructions given to corrections officers regarding their response to reports of an inmate experiencing a serious health event.
Experts say consequences are needed
Sarah Crellin from the Aboriginal Legal Service NSW/ACT said the outcome of the findings was “predictable”, agreeing Mr Reynolds’s death was preventable.
“Together, all of us, all of us must call on the NSW government to ensure the human right of health care is not away when someone is taken into the care of the state,” she said.
While Ms Crellin welcomed the deputy coroner’s reviews, she said accountability was needed.
“Constant reviewing will not create the change needed to save lives, if there are no consequences for failing to implement results of reviews we are just waiting for more deaths in custody.”
Mr Reynolds’s sisters Taleah and Makayla said they would never give up on getting justice for their brother.
This year marks 30 years since the Royal Commission into Aboriginal Deaths in Custody handed down its findings.
More than 440 Aboriginal people have died in custody since then.
Three Aboriginal people have died in custody in the past week.
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