For 16 minutes an Indigenous man was left unconscious in his prison cell before dying, in what his mother describes as a system lacking care and compassion for human life.
A series of missed opportunities culminated in the preventable death of 32-year-old Yorta Yorta and Gunaikurani man Joshua Kerr who likely died from cardiac arrhythmia or a seizure after ingesting a significant amount of meth, Victorian coroner David Ryan said in inquest findings on Monday.
Hours before his death on August 10, 2022, Kerr's behaviour became erratic, lighting fires in his cell at Port Phillip prison before he was taken to St Vincent's Hospital after burning his hand.
Before going to hospital, the inmate had disclosed to a nurse and separately to prison officers he had taken methamphetamine.
Kerr's behaviour continued to spiral while at hospital where he became agitated, refusing treatment and wanting to return to the prison.
Due to concerns over his escalating abusive behaviour towards hospital staff, Tactical Operations Group police "prematurely" cancelled their escort and took him back to prison before doctors could redress his wounds, assess his ice use disclosure and notify staff or formally discharge him.
A hospital discharge summary was not provided to prison nurses once he returned.
Instead "vague" information was passed on.
Kerr's behaviour gradually deteriorated after returning to a cell in the medical wing at 4.45pm, with a psychiatric nurse raising his risk rating to the highest level after an assessment.
There was an unwritten understanding in the prison that the door to Kerr's cell could not be opened without TOG officers nearby.
"I'm dying" rang through Kerr's intercom at 6.27pm.
By 7.40pm, Kerr's movements began to slow, and he was completely unresponsive about 8.02pm.
A code black - medical emergency - was called eight minutes later.
It took 16 minutes from when he was discovered unconscious for his cell door to be opened as prison staff waited for TOG officers.
Kerr was pronounced dead at 8.40pm.
Outside court, Kerr's mother Aunty Donnas Kerr demanded the coroner's findings be urgently implemented in all prisons.
"The coroner found that the correctional and medical staff at the prison should have known my son was dying," she said.
"For hours they didn't go into his cell or call an ambulance.
"This is what is wrong with our system - the lack of care and compassion for human life, or Aboriginal lives."
A post mortem found an "exceptionally high" level of ice in Kerr's system which suggested it was likely ingested orally.
"It was a preventable tragedy that devastated his family and community," Mr Ryan said.
"Josh's passing could have been prevented if his emerging drug-induced erratic behaviour had been recognised and appropriately treated."
The coroner found there were multiple opportunities for prison staff to have sent Kerr back to hospital over his escalating behaviour.
"I am satisfied that Josh would have very likely survived had he remained in hospital," he said.
The TOG directive was too strictly and inflexibly interpreted by staff and a lack of training on the impacts of ice on decision-making and the need for it to be treated also played a role in Kerr's death, the coroner said.
"Medical staff needed to be more forceful in advocating for Josh and seeking access to his cell and correctional staff needed to be more willing to facilitate that access," he said.
He made a number of recommendations including better training for prison officers and nurses to recognise drug-affected prisoners and to reinforce their authority when it came to the health of inmates.
He also called for better communication standards between prison and hospital staff to ensure all information is passed on.
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