The prison where Indigenous man Michael Baker died had just one regular GP working six hours a week to care for hundreds of inmates, an inquest has revealed.
The 44-year-old Awabakal man died alone in his cell at the Lithgow Correctional Centre, west of Sydney, on June 25, 2019.
A coronial inquiry concluded on Thursday that while Mr Baker's cause of death was cardiac arrhythmia, understaffing of prison doctors and nurses meant the care he received fell "well short of an appropriate level".
Mr Baker spent a short stint in hospital in the months leading up to his death after collapsing in his cell, with one guard describing him as appearing to have a seizure.
However, after being discharged from hospital and returning to prison, Mr Baker received no follow up care from a GP.
"Even after such a serious episode, Michael did not receive the care he required and deserved," Deputy State Coroner David O'Neil said in his findings.
"This was a gross lapse in the standard of care provided to Michael."
Mr O'Neil called Indigenous deaths in custody a "blight on society" that would continue as long as the correctional services system remained underfunded.
Despite the failings identified in Mr Baker's care, the inquiry did not identify any breaches of Corrective Services NSW policy, nor did it make any formal recommendations.
The theme of medical staff at Lithgow prison being subjected to an overwhelming workload was apparent during the inquest, Mr O'Neil said.
The attending GP at Lithgow Correctional Centre, John Dearin told the inquiry some patients reported waiting over six months to be seen.
The court heard Dr Dearin visited the jail one day a week for six hours to care for up to 420 patients - in addition to occasional visits by another GP - which was deemed in the findings to be "wholly insufficient".
"Ideally I should have seen (Michael) much sooner, but tragically I didn't," Dr Dearin told the inquest.
In addition to other conditions, Mr Baker suffered from "extremely painful" ingrown toenails for which he unsuccessfully sought treatment.
Mr Baker was referred to see a podiatrist and be issued with wider toed shoes to relieve pressure on his feet, neither of which eventuated.
"Michael spent the last months of his life in pain which was clearly identified and treatable," Mr O'Neil said.
Emma Parker from the Aboriginal Legal Service said the answers to addressing Aboriginal deaths in custody already existed following a royal commission more than 30 years ago.
"How is this still happening?" Ms Parker asked.
"Everyone should have a right to adequate health care. This is not the case at the moment for those in custody.
"They have the tools to reduce deaths in custody, but government need to act on it."
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