An Indigenous man who died in custody in 2015 had "suboptimal medical care" at a Junee Correctional Centre before he died of organ failure, a coronial inquest has found.
Wanaruah man Danny Whitton was just 25 years old when he died at a Sydney hospital on November 9, 2015, after being airlifted there from Wagga Base Hospital.
In the days before the father of two's death, he complained of vomiting, kidney pain and urinating blood.
In findings handed down on Friday, Deputy State Coroner Elaine Truscott said Mr Whitton died after an overdose of paracetamol, adding he had engaged in "illicit and unsafe drug use" because he could not get a place in the methadone program.
According to Magistrate Truscott's findings, when Mr Whitton became sick was "difficult to pinpoint", but expert evidence suggests he took the fatal dose of paracetamol several days before his death.
When Mr Whitton was at the prison medical centre and was asked if he had taken anything, he responded that he had not. But Magistrate Truscott said Mr Whitton had been punished previously when he was found with illicit drugs.
"That an inmate believes that his health condition would not be kept private from the custodial services so that he could secure appropriate health care is extremely concerning, particularly where a consequence of death could, or as in this case, did ensue," she said.
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An expert in emergency medical care said they had a "number of criticisms" about Mr Whitton's care at the Junee jail's medical unit.
Magistrate Truscott said his condition was not appropriately investigated or appropriately monitored.
"His deterioration was not appropriately actioned in a timely manner due to overall suboptimal care and a significant misunderstanding of the transfer procedure of a patient from the health clinic at Junee Correctional Centre to the Wagga Base Hospital," she said.
"Danny's condition was irrecoverable despite appropriate intervention at that hospital and then his transfer to the Royal Prince Alfred Hospital. Danny died whilst he was in the custody of Corrective Services NSW."
A spokeswoman for The GEO Group Australia, which operates the jail, said the company offers its condolences to Mr Whitton's family.
"GEO acknowledges the recommendations handed down by the Coroner on Friday and has already changed healthcare practices and procedures in line with these," she said.
"However, GEO will also carefully consider all of the Coroner's findings and any further recommendations."
Magistrate Truscott acknowledged changes have already been made at Junee Correctional Centre following Mr Whitton's death, including reducing how much paracetamol can be given to inmates daily.
However, she still made recommendations, including that the GEO Group ensure that all health staff are aware an ambulance can be called for a prisoner without a doctor's authorisation.
Magistrate Truscott also recommended to Corrective Services that CCTV capturing the last week of a person's life be kept when they die in custody until indicated it is not required for an inquest.
The recommendation was made after footage that was asked for had already been deleted in Mr Whitton's case.
Magistrate Truscott offered her condolences to Mr Whitton's family and said it was regrettable that the inquest findings were only being delivered several years after his death.
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