Failures in the response to Nathan Reynolds' severe asthma attack in 2018 contributed to the Anaiwan and Dunghutti man’s death, the NSW Coroner’s Court heard on Thursday.
In handing down the findings of the coronial inquest, Deputy State Coroner Elizabeth Ryan called the response to Mr Reynolds' medical emergency 'confused, uncoordinated and unreasonably delayed'.
'The delay deprived Nathan of at least some chance of surviving his acute asthma attack,' Magistrate Ryan said.
'These failures were due both to numerous system deficiencies, and to individual errors of judgement.'
Mr Reynolds was severely asthmatic but despite his chronic condition, there was no asthma management plan in place for him.
Failure to properly manage Mr Reynolds' condition in the lead-up to the attack was another factor in his death, said Magistrate Ryan.
'The health care he had received since entering custody was inadequate,' she said.
'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 the findings of the inquest showed the need for changes in the way asthma is managed in the NSW justice system.
Mr Reynolds was 38-years-old when he suffered a severe asthma attack in the minimum security wing at John Moroney Correction Centre in western Sydney.
The coroner also acknowledged the continued overrepresentation of First Nations people in custody.
Magistrate Ryan acknowledged two more deaths in NSW custody this week - a man in his mid-30s, who died at Long Bay Hospital and a woman in her mid-50s, who died at Silverwater Women's Prison.
A death in Victoria brings this week’s tally to three, after a man died at Ravenhall Correctional Centre on March 7.
