© Provided by The GuardianPhotograph: Luke Costin/AAP
A 36-year-old Aboriginal man who died on the floor of prison from an asthma attack in 2018 was deprived of "at least some chance" of surviving by the "unreasonably delayed" response to his emergency by prison guards and health staff, the NSW coroner has found.
But the coroner still found that Anaiwan-Dunghutti man Nathan Reynolds died of "natural causes" that were partly exacerbated by deficiencies in the management of his severe asthma.
"Nathan's medical crisis on the night of 31 August required an emergency response. But the response he received fell well short of this. It was confused, uncoordinated and unreasonably delayed," the deputy state coroner, Elizabeth Ryan, said.
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"The delay deprived Nathan of at least some chance of surviving his acute asthma attack. These failures were due both to numerous system deficiencies and to individual errors of judgement."
During the inquest in October last year, the coroner was told that prison officers took about 10 minutes to respond to calls for help. Officer Matthew Fawzy told the court he had been waiting for a colleague to see Reynolds. When asked why this took roughly 10 minutes, he said: "I can't think of anything."
© Photograph: Luke Costin/AAPMakayla Reynolds (right) and Taleah Reynolds, sisters of Nathan Reynolds, found to have died from 'natural causes' exacerbated by deficiencies in asthma management.
When asked why he didn't run to Reynolds, the prison officer said he had been trained to avoid that. "We were taught never to run unless it's an officer actually getting assaulted," Fawzy said.
Taking Nathan's call at 11.27pm for help as the starting point for each of the following events,the coroner said it took more than eleven minutes for correctional officers to reach his side, 13 minutes for a nurse to be summoned, 22 minutes before a nurse arrived at his side and 47 minutes before ambulance paramedics attended him.
"These time frames cannot be accepted as adequate or appropriate," she said.
During the inquest, fellow inmate Jeremy Preo, who was trained in first aid, cried as he told the coroner he placed Reynolds in the recovery position and did his best to open the man's airways.
"He's done like a big gurgle and that's when I started rubbing my arm on his back and said, 'Mate, keep breathing'," Preo told the NSW coroners court while wiping his eyes. "He was alive then. He could hear me."
But Preo said he was distressed when the nurse arrived and rolled Reynolds onto his back.
"I've seen her ... slap Nathan in the face and aggressively shake him, and telling him to wake up," Preo told the court. "The nurse then said to [prison officer John Fifita] that Nathan's had a drug overdose."
The nurse said she asked other inmates what Reynolds had taken when she arrived on the scene about 11.50pm and saw his pupils were fixed. Wright told the court she gave him naloxone, which reverses the effects of a drug overdose.
She said she did not recall anyone telling her about his asthma and denied slapping or shaking him.
In delivering her findings, Ryan said the failures in Nathan's care went beyond what happened that night. The care he received since entering custody five months before he died was "inadequate".
"It failed to reduce his risk for a fatal asthma attack. It did not comply with established treatment for the management of severe asthma. It did not even comply with NSW Health's own policies to prevent chronically ill prisoners from deterioration and death. These failings significantly increased Nathan's risk for the fatal attack which took his life on the night of 31 August," Ryan said.
However, she said her recommendations resulting from his inadequate care were "not focused on attributing blame", and were "made in the hope that people like Nathan who enter custody with conditions of severe asthma will have a better chance of avoiding a life threatening attack, and of surviving one should it happen".
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Reynolds did not receive an assessment of his asthma or a management plan at the jail, despite the intake nurse noting his history of asthma, including that he had a nebuliser at home, when he was first admitted to the prison in May 2018.
The nurse recommended that Reynolds' asthma be assessed. A month later - even after he was hospitalised having suffered a severe asthma attack - the assessment still did not occur.
The court heard that the intake nurse's note recommending an assessment was at some point replaced with one saying Reynolds refused to go to the emergency department.
Reynolds' family demanded accountability from Justice Health and NSW Corrective Services for the failings in his care.
"It's soul-crushing knowing that at just 36 years old, Nathan died on the cold floor of a prison, separated from his family and loved ones. Words can't describe our pain.
"We are also angry because Nathan's death was preventable. He would not have died if he weren't in prison. This can't just be treated as an accident - it must be recognised as a huge institutional failing and people must be held responsible."
Karly Warner, CEO of the Aboriginal Legal Service NSW/ACT, said processes in prisons to manage chronic health conditions "were hardly worth the paper they're written on, as staff were either unaware of them or failed to follow them".
"In the four months he was in prison, Nathan's health steadily deteriorated and there were clear signs that he was heading for an acute asthma attack. He was cut off from community healthcare and entirely in the hands of Corrective Services NSW and Justice Health, who failed in their responsibilities to him," she said.
"That failure cost Nathan his life. This is why we say that Aboriginal people's lives are put at risk when they are sent to prison."
Two more Aboriginal people died in NSW prisons last week.