Aboriginal woman Tanya Day fell and hit her head five times in a Victorian police station but it was hours before officers called paramedics.
The 55-year-old Yorta Yorta grandmother was arrested and placed in a cell after being drunk on a regional train on December 5, 2017. She died 17 days later from a brain injury.
At an inquest into her death on Tuesday, custody supervisor Sergeant Edwina Neale was shown CCTV footage of Ms Day stumbling in the cell before repeatedly falling between 4.22pm and 4.45pm.
"She looks very drunk there but she's not a lot different to many other drunks," she told the inquest of Ms Day.
When asked if Ms Day was at risk of a fall, Sgt Neale responded: "All drunks are at risk of falling and cracking their head in a police cell."
Five minutes after the falls, footage showed leading senior constables Danny Wolters and Wayne Caines checking on Ms Day through a cell window for just a few seconds before walking away.
Sen Const Caines earlier told the inquest the officers did not enter the cell to give Ms Day "privacy and dignity".
It's unclear if Ms Day verbally responded to the men, as required by police guidelines.
"That's a completely inadequate check, what you've witnessed there?" Peter Morrissey SC, the lawyer representing the Day family, asked the sergeant.
"It looks it, yes," Sgt Neale said.
Thirty seconds later, Ms Day is shown falling head-first against the cell wall and bench. An autopsy established this fall caused her fatal haemorrhage.
"If you had seen that fall, you would've raced straight in there, wouldn't you?" Mr Morrissey asked.
"Yes," Sgt Neale replied.
Sgt Neale said she tasked Snr Const Wolters with checking on Ms Day every 20 minutes, either in person or on CCTV.
But he later told her said Ms Day would "get up and become agitated" when he did a physical check and suggested they be pushed out to 40 minutes. Sgt Neale agreed.
Nobody entered Ms Day's cell between 3.57pm and 8pm.
When asked if the decision to push out checks to 40 minutes was criminally negligent, Sgt Neale said she disagreed.
"In fact, at that point she was bleeding to death, wasn't she?" Mr Morrissey asked.
"I don't know that," Sgt Neale replied.
The court heard a recording of a phone call made to paramedics at 8.05pm by Snr Const Wolters.
“We have a female in custody for drunk and she’s fallen over inside the cell and has a lump on her head that we need to get checked out,” he told the operator.
Snr Const Wolters said that Ms Day he “saw her slip over an hour ago” from the concrete bed to the floor but that she was conscious, talking, and breathing.
“She’s preferring to go to sleep and we’re a bit worried about that,” he said.
“We do have some family coming in about an hour and a half and we want to release her into their care, but want to make sure she’s checked out first.”
The inquest continues, with Coroner Caitlin English examining whether systemic racism contributed to Ms Day's death.