The family of Nathan Reynolds, who died in custody after suffering a severe asthma attack, say they will continue to pursue justice.
After the coroner handed down her findings on Thursday morning, Makayla and Taleah Reynolds - Nathan's sisters - told NITV News the inquest into their brother's death may be over, but their fight is not.
"Our fight is not done," Taleah Reynolds said.
"This isn't the end for us at all. There's a lot more work to do around deaths in custody. We'll continue to fight after this."
Mr Reynolds - an Anaiwan and Dunghutti man - died at a western Sydney prison in 2018.
The family of Nathan Reynolds. Source: AAP
"Losing him has left a huge hole in the lives of our family," Taleah said.
"We miss him every day. It is soul-crushing to know that at just 36-years-old Nathan died on the cold floor of a prison."
Mr Reynolds called for help on the night of August 31, 2018, while suffering an asthma attack.
Prison officers responded to his call, taking 10 minutes to walk to his location, and only calling the nurse after they had verified that Mr Reynolds was in difficulty.
The nurse arrived 22 minutes after Mr Reynolds' initial call for help. She used naloxone on Mr Reynolds, which reverses the effects of opioids or drugs.
At the inquest, she denied this choice was influenced by prejudice.
'Confused, Uncoordinated, Delayed'
In handing down the findings Deputy State Coroner Elizabeth Ryan said the assistance Mr Reynolds received when he called for help "fell short" of what was required.
"It was confused, uncoordinated and unreasonably delayed," she said.
"The delay deprived Nathan of at least some chance of surviving his acute asthma attack.
"These failures were both due to numerous system deficiencies and to individual errors of judgement."
Aboriginal Legal Service NSW/ACT solicitor Sarah Crellin, who represented the family, said Mr Reynolds' death was preventable.
"Today's findings articulate that there were significant failings by Justice Health," she said.
"The outcome where Nathan suffered a severe asthma attack was predictable and preventable.
"Corrective Services and Justice Health failed Nathan on two counts - they failed to provide ongoing care and management of his chronic asthma, and they failed to provide emergency medical care when it was needed most.
"These failures cost Nathan his life."
Taleah Reynolds said the findings demonstrated that the coroner had heard the family's concerns and had taken on their recommendations, but she that she wants to see the medical staff involved held accountable.
"We came to the Coroner's Court today hoping to see accountability," she said.
"We want the nurses and the doctor who saw Nathan to be accountable for their failures, not just with a slap on the wrist, but with real consequences."
