Use of restraints on prisoners in hospital has taken away their dignity and their guards' compassion, a coroner has heard.
Judge Elisabeth Armitage is holding a mandatory inquest into the death of terminally ill Indigenous man Mati Tamwoy at Royal Darwin Hospital while on he was remand.
Following Royal Commission into Aboriginal Deaths in Custody recommendations, custodial settings are required to report in real-time all Aboriginal deaths in police or prison settings.
After the 66-year-old man's death, the prison failed to notify the federal body, which Darwin Correctional Centre general manager David Gordon said was his oversight due to "a perfect storm".
Mr Gordon said Mr Tamwoy's 661 days on remand was reflective of systemic pressures.
"When we talk about remand 47 per cent of prisoners are on remand, for the women it's as high as 60 per cent," he said.
"There were 314 prisoners that spent an average of 109 days on remand, and when they went to court charges were withdrawn, dismissed, or released with time served."
The majority of prisoners shouldn't be in jail, said Mr Gordon, however Mr Tamwoy "was happy in jail".
Judge Armitage said upon review it was clear Mr Tamwoy could access the medical care he needed when incarcerated.
The ongoing restraint of Mr Tamwoy while in hospital was the core issue investigated by the coroner.
On Tuesday, she heard from four corrections officers who gave conflicting evidence about their understanding of restraining a prisoner while they were in hospital.
The court heard Mr Tamwoy spent most of his palliative treatments shackled to a bed before dying on November 17, 2023.
Judge Armitage summated there was a problem between standard operating procedures and commissioner directives, which Mr Gordon agreed were inconsistent.
He said after listening to his officers the standard operating procedure regarding the restraint of prisoners in hospital did not provide for the dignity of prisoners or compassion of staff.
"We have lost sight of the humanity aspect when we're dealing with prisoners in most circumstances," he said.
"I saw a lot of compassion in the officers yesterday, we squash that by being too prescriptive not allowing for the dignity of persons."
Reflecting on Mr Tamwoy's terminal condition, Judge Armitage said she would consider herself "seriously unwell" if she was in his position, even if she wasn't "presenting as acutely unwell".
Under the restraints for medical escorts' directives being seriously unwell makes you excluded from being handcuffed and shackled, however that was not the case for Mr Tamwoy.
"It's disturbing and upsetting that, in fact, during the course of his treatment, he was restrained for most of his hospital visits," Ms Armitage said.
Mr Gordon agreed with Ms Armitage and clarified a review by NT Corrections was looking into the policies.
He suggested there not only would be clarification, but a review of classifications regarding "high-risk and low-risk" environments was underway.
"If we're taking a prisoner to A&E, we need, because that is a high-risk area, to have a level of restraint," he said.
Mr Gordon shared his condolences with the court and said the prison was committed to doing better.
The inquest concludes on Wednesday with the coroner expected to hand down her findings in 2025.
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