The coroner has handed down her findings over the death in custody of Kamilaroi, Gumbaynggirr and Wakka Wakka man, Tane Chatfield.
Following a week-long inquest, Deputy state coroner, Magistrate Harriet Grahame, found on Wednesday that Mr Chatfield had died as a result of self-inflicted hanging and described the care provided to Tane by a Justice Health nurse the morning of his death was "inadequate."
The coroner recommended the urgent removal of all hanging points at the Tamworth Correctional Centre and that both the centre and NSW Corrective Services actively recruit Aboriginal health workers.
It was also recommended that the Nursing and Midwifery Board of Australia consider a review of the nurses conduct.
Tane Chatfield was 22-years-old when he died in custody in Tamworth, a New South Wales regional city around 400 kilometres north-west of Sydney, in September 2017.
A timeline of events presented to the court detailed how Mr Chatfield suffered multiple seizures and was hospitalised overnight, before returning to prison without a discharge summary.
That morning, a fellow inmate reported seeing Mr Chatfield hanging in his cell.
He was then taken to an intensive care unit at Tamworth hospital where he died two days later.
NSW Corrective Services at the time said Mr Chatfield's death was not suspicious, telling his family he took his own life.
The inquest heard from Mr Chatfield's ex-cellmate, multiple correctional officers, the nurse unit manager, the prison security manager and his family members.
Footage presented at the inquest showed Mr Chatfield's body being lifted out of a cell and carried into a corridor within the cell-block shortly after paramedics had arrived.
He was then put on life support in Tamworth Hospital's intensive care unit.
The Chatfield family has been campaigning for changes to the justice system and reducing Aboriginal deaths in custody.
At the time of Tane’s death, there were 88 inmates in custody at Tamworth Correctional Centre, of which 45 were Aboriginal.
-MORE TO COME
Readers seeking support and information about suicide prevention can contact: Lifeline on 13 11 14, the Suicide Call Back Service on 1300 659 467 or find an Aboriginal Medical Service here. There are resources for young people at Headspace Yarn Safe.