Inquest findings into an Indigenous man who died in a Sydney jail has found the response to his medical emergency was “confused, uncoordinated and unreasonably delayed”.
Deputy state coroner Elizabeth Ryan handed down her findings on Thursday into the death of Nathan Reynolds of Anaiwan and Dunghutti heritage.
Ms Ryan said the delayed response to Mr Reynolds’ acute asthma attack deprived him of “at least some chance of surviving”. She has made a number of recommendations to prevent similar deaths.
The inquest also examined how First Nations people in Australian prisons were “grossly” over-represented, a fact first found in a 1991 Royal Commission Inquiry into Aboriginal Deaths in Custody.
“Thirty years later we have no reason to suppose those numbers will fall,” she said.
The 36-year-old died on a concrete floor in a minimum-security section of John Morony Correctional Complex in Berkshire Park in September 2018, surrounded by paramedics, staff and concerned prisoners.
There was no asthma management plan in place for Mr Reynolds, despite him receiving six Ventolin puffers in the eight weeks before his death.
The repeated issuing of asthma puffers was “a big red flag there’s something really going wrong with his asthma”, respiratory specialist Greg King told the inquest in October 2020.
Prison officers responded to Mr Reynolds radioed call for help by walking for 10 minutes to his location and only calling the nurse once they had arrived and verified he was in difficulty, the inquest was told.
That nurse – arriving 22 minutes after the initial call – found he was not breathing and had fixed pupils.
She denied her use of naloxone, which reverses the effects of opioids or drugs, and asking what Mr Reynolds had “taken” was influenced by prejudice.
“I was hoping that it would help him. I was looking for a reversible cause of why he wasn’t breathing,” she said.
Professor King said Mr Reynolds needed advanced life-support care, like that from paramedics or in a hospital, well before the nurse arrived at 11.49pm on 31 August.
The inquest also heard another nurse had noted Mr Reynolds’ history of asthma, including that he had a nebuliser at home, when she saw him on his arrival to the prison in May 2018.
But her note that his asthma should be assessed wasn’t acted upon before a severe asthma attack on 3 June.
The note was later overridden in the system.
The inquest findings found his healthcare since entering custody was in critical ways, inadequate.
“It did not even comply with NSW Health’s own policies to prevent chronically ill prisoners from deterioration and death.”
Taleah Reynolds said it was “just so frustrating” to sit through witness after witness who could have prevented her brother’s death.
“It’s total disregard to my brother, to a human,” Ms Reynolds said on the inquest’s final day of hearings.
“It’s just no care. No duty of care.”
Ms Ryan thanked Mr Reynolds’ family for their participation with dignity and courage each day at the inquest, saying it would have been profoundly distressing for them to hear “Nathan did not receive the care he needed”.
