Urgent, systemic change is needed to prevent more deaths in custody, the family of 36-year-old Anaiwan man Nathan Reynolds said outside of the NSW Coroner’s Court on Wednesday.
Mr Reynolds died after a severe asthma attack in a minimum security wing at the John Moroney Correctional Centre in western Sydney two years ago.
Over eight days the inquest into his death has heard that Mr Reynolds was severely asthmatic – requiring four-five Ventolin puffers over a six week period – that there was no asthma management plan in place despite his chronic condition, and that on the night of his death he was administered Naloxone, which is commonly used to treat drug overdoses.
Earlier on Wednesday, Mr Reynolds' family said it had been traumatic and frustrating to hear graphic details about Nathan’s final moments throughout the inquest, labeling his care “a total disregard".
"You get angry, you get angry, you get angry, and I think I've gotten to the point - it's not anger anymore,” Mr Reynold’s sister Taleah Reynolds said.
"I've reached the point of anger tolerance and I don't know what emotion to put to it now.”
The CEO of the NSW/ACT Aboriginal Legal Service, Karly Warner, said there were many systemic failures which contributed to Mr Reynolds’ death.
"Nathan should not have been imprisoned in the first place,” she said.
“Aboriginal people must be supported to live strong in culture with family and in community. What we've seen over the last few weeks and what we want to make sure, is that this never happens to another family again."
Final witnesses on Wednesday included prison clinic nurse RN Pant and respiratory specialist Dr Gregory King.
Through cross-examination it was revealed Mr Reynolds was issued four or five Ventolin puffers for his asthma in a six-week period. One Ventolin puffer has 200 puffs.
When asked if Mr Reynolds' puffer use would be considered a “red flag”, Mr Pant replied “yes”.
Dr King gave evidence on the severity of Mr Reynolds' asthma and the response time of staff and medical intervention in the moments before his death.
Counsel assisting Justice Health, Ragni Mathur, proposed that a positive outcome of Mr Reynolds' death could be that it’s “used to promote the management of asthma”.
'Nathan was the joker of our family'
A recording of the last conversation Taleah Reynolds had with her brother was played to court, where they discussed Ms Reynolds' upcoming trip to Bali and Mr Reynolds' release a few days later.
“I would’ve never imagined that was the last conversation I’d have with Nathan,” she said.
In their family statements Mr Reynolds' sisters Taleah and Makayla remembered him as “a joker”, “a typical boys’ boy” and a “big softie at heart”.
They said he had “deep respect for his family” - caring for his grandparents as well as the young ones - and that loved his job as a tradie.
“Nathan made a lasting impression on everyone he met. He was our brother, but he was also a son, father, step-father, nephew and grandson,” the family’s statement reads.
“Nathan was the joker of our family - he had a really great sense of humour and loved his footy, golf and fishing.”
“Our lives are forever changed by his death.”
Speaking in court Taleah Reynolds said taking on the role of family spokesperson had been “incredibly trying and difficult”, and that she couldn’t protect her family from the “heartbreaking details” of Nathan’s last moments.
“Loving him was easy,” she said.
“Nathan is more than a statistic, more than a hashtag… we’ll make sure his death won’t be in vain.”
The court also heard from Mr Reynolds' former partner and his stepchildren.
The inquest was adjourned until December 11, with a directions hearing expected in November.