Nathan Reynolds did not receive an assessment of his asthma or a management plan from healthcare workers at the Sydney prison where he would later die from the lung condition, an inquest has heard.
The 36-year-old Anaiwan man died after struggling to breath and calling for help at a South Windsor prison's minimum-security wing late on August 31, 2018.
When he was first admitted to the prison on May 10, 2018, an intake nurse noted his history of asthma, including that he had a nebuliser at home, in an internal system.
The nurse said Mr Reynolds' asthma should be assessed.
By the time he presented with a severe asthma attack on June 3, the assessment had not occurred. The note would later be overridden in the system.
The registered nurse who treated Mr Reynolds at the prison that day, Parveen Samant, has told the NSW Coroners Court she did not check to see if he had undergone a chronic disease screening or asthma assessment, or had an asthma management plan developed for him.
"When he came in that day with the emergency, I totally focused on his recovery from the asthma attack," she told the inquest on Monday.
"I should have checked the asthma care management and chronic disease screen ...I should have checked that before I (left)."
The intake nurse's note recommending an assessment was at some point replaced with a note saying Mr Reynolds refused to go to the emergency department.
Ms Samant said she did not know how the note had been changed and that she had not discussed attending hospital with Mr Reynolds.
She administered a ventolin nebuliser to Mr Reynolds, gave him prednisone, a steroid that increases lung function, and recommended he see a doctor.
Mr Reynolds presented at about 2pm and Ms Samant's shift ended at 3.30pm. He remained under observation until about 5pm.
An asthma assessment by a primary health nurse would have taken up to an hour and required Mr Reynolds to go without his puffer for a number of hours prior to the appointment, the court heard.
If he had undergone an assessment, he would have been called back to medical staff periodically so his asthma could be reviewed.
A month after his asthma attack, Ms Samant interacted with Mr Reynolds again when distributing medication to him. He had still not had a chronic disease screening or received an asthma management plan.
But Ms Samant said nurses were not allowed to discuss health issues with patients when distributing medication.
The inquest is continuing on Monday, with another registered nurse to give evidence.