Pam White-Row Row is on a quest for change, driven by a grief that is immeasurable.
Aboriginal and Torres Strait Islander readers are advised this article contains images and the name of someone who has died.
WARNING: This story contains references to suicide.
It's been six years since she received news that turned her life "upside down".
Her cousin and cultural brother, Frederick Row Row, a Kullilli and Darumbal man, had taken his own life in the Capricornia Correctional Centre in Rockhampton.
"I went through suicidal thoughts myself. I developed disorders and have had to get up every hour overnight, just washing my hands, I wasn't sleeping properly," Ms White-Row Row said.
"[But] I had to do something. I couldn't just sit around and live my life this way. I have to fight for him and try to fight for some kind of justice."
Every Indigenous death in custody takes Ms White-Row Row back to that day in 2016.
But it was the death of another inmate, an Indigenous man, at the same correctional centre on August 9 that spurred her into launching an online petition to eventually take to the Queensland government for legislative change.
It has almost 5,500 signatures so far.
"There's too many families suffering," she said.
Push for 'Fred's law'
Ms White Row-Row is lobbying for what she wants to be called "Fred's Law", mirrored on the state's Ryan's Rule.
Ryan's Rule allows patients or their guardians to ask for an immediate clinical review if their health condition is not improving as expected or is getting worse.
Ms White Row-Row said under her proposal, prisoners requesting urgent medical attention would be seen without delay.
"[It] gives inmates and their families power for the prison officers and psychologists to address the prisoner immediately and not ignore what's happening with suicidal inmates and/or their mental health state or medical issues that one is suffering," the petition stated.
"[It] allows the prisoner or people held in the watch house to be able to call family or friends for support on the outside immediately, and an ambulance to be called immediately when a prisoner or family member activates 'Fred's Law'."
Queensland's Minister for Corrective Services, Mark Ryan, said the department was always looking at ways to improve safety.
"Including upgrades to technology to help correctional officers better monitor prisoners, particularly those who are identified as being at risk of harming themselves and others," he said.
Inquest findings
Ms White-Row Row's idea for 'Fred's Law' was born from her family's dissatisfaction with coronial findings into her brother's death handed down last November.
The inquest found Mr Row Row was moved to a medical unit high-risk cell days before his death as his mental health deteriorated.
But he was deemed less risk to himself the following day and placed in the detention unit, even though at one stage he expressed some "fleeting suicidal ideation" and wanted to return to the medical unit.
While he was briefly left unsupervised, Mr Row Row took his own life.
Coroner Terry Ryan found there was inadequate staff to monitor Mr Row Row's wellbeing on the day of his death and he was not receiving ongoing mental health support in custody as he "did not meet the criteria".
"The focus of his interactions with prison psychologists was suicide risk assessment," Mr Ryan stated.
"He did not receive any ongoing mental health treatment or support from Queensland Health or another agency."
Mr Ryan, however, noted that some changes had been made since Mr Row Row's death in custody.
'Nothing's really working'
The Row Row family made several recommendations to the inquest, including the need for improved and increased cultural-awareness training for staff, and more training on risk assessments for First Nations prisoners.
They also called for more funding to improve psychological and mental health services within prisons, allowing community-based providers access and more male psychologists to provide culturally appropriate services to First Nations prisoners.
While Mr Ryan identified the need for more culturally appropriate mental health responses, he said there were "several recent initiatives that may assist in this regard".
Ms White-Row Row said the findings were "very disappointing" and she felt her family's recommendations were ignored.
"Nothing's really working … more can be done, deaths in custody just keep happening and happening.
"I can't move on with my life, I can't heal, until these deaths in custody slow down."
'Enhanced care programs' in place
There were 512 Indigenous deaths in custody between the end of the Royal Commission into Aboriginal Deaths in Custody in 1991 and March this year, according to the Australian Institute of Criminology.
At the time of the coronial findings into Mr Row Row's death, Corrective Services Minister Mark Ryan described it as a tragic incident.
"In the five years since this tragedy, Queensland Corrective Services has put in place enhanced care programs for prisoners and implemented further culturally appropriate training programs for custodial officers," he said.
"I am advised that QCS now has nationally accredited Aboriginal and Torres Strait Islander mental health first aid instructors on staff."
For Ms White-Row Row, it's simply not enough.
"I think once change starts to happen, that's where not just myself but a lot of families around Australia can heal, can move forward," she said.
"But until then, it's just fighting and fighting, and it gets exhausting at times, it gets very stressful at times."
