A prison guard lied to Indigenous woman Veronica Nelson about calling a nurse to help her in the hours before she died.
Veronica screamed in pain and complained of cramps in her legs and fingers before she was found dead in her cell at Melbourne's Dame Phyllis Frost Centre in January 2020.
She had been arrested three days earlier on suspicion of shoplifting and was denied bail.
Veronica had made more than a dozen calls to prison guards for help on the night she died, an inquest into her death has been told.
When she called guard Tracey Brown on the intercom at 2.13am, Ms Brown advised her to drink fluids and told her she did not think the nurse would return to her cell.
Veronica made another call at 2.42am saying she was cramping badly, and Ms Brown pretended she had called the nurse when she had not.
In the next call at 3.33am Ms Brown again lied to Veronica, telling her she could not get anyone to come to her cell.
Under examination Ms Brown agreed she had lied to Veronica, and she had failed in her duty to check on her after she became unresponsive during an intercom exchange.
While prison nurse Atheana George had given Veronica medication through a trap in her cell door earlier that night, she had not gone into the cell to check on her.
Veronica was found dead about 7.30am on January 2, several hours after her final call.
The Yorta Yorta woman died from undiagnosed Wilkie's syndrome, in a setting of heroin withdrawal.
More than 60 witnesses are expected to be called at a month-long inquest, examining the adequacy of prison healthcare, the impact of Veronica's Aboriginality and Victorian bail laws.
The inquest is continuing.