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.
