Indigenous man Danny Whitton was just 25 years old when he died at a Sydney hospital on November 9, 2015, after being flown there from Wagga Base Hospital.

In findings handed down on November 19, Deputy State Coroner Elaine Truscott said Mr Whitton - a Wonnarua man - died after an overdose of paracetamol and that he had received "suboptimal medical care" at the Junee prison.

Mr Whitton's family had to wait six years for the coroner's findings and his mother, Kylie Knight, has spoken of her disappointment.

"It's very disappointing to find that no one's going to be held accountable," she said.

"I feel so many things about it, disappointed, disgusted, hurt, and I don't find any justice in the findings.

"I feel that someone should be held accountable so the next time someone works in this prison, they might take their job a bit more seriously and their duty of care."

Ms Knight said it has been "sheer agony" and the family still has no closure.

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"Danny was a human being. He was a dad. He was a son. He was a brother. He was a nephew. He was a grandson," she said.

"I'd like his legacy to be to prevent other boys in custody from becoming another Danny Whitton and suffering the way he did."

The case of Mr Whitton was just one that the Aboriginal Legal Service (ALS) referenced at a parliamentary inquiry into the Coroner's Court on Tuesday.

Sarah Crellin, the acting principal legal officer at ALS, appeared before the Inquiry into the Coronial Jurisdiction in NSW to highlight how inadequate healthcare contributes to deaths in custody.

"A prison sentence should not be a death sentence, but substandard prison healthcare is taking Aboriginal lives.

"People behind bars are dying of asthma attacks, paracetamol overdoses and ear infections.

"These are standard health issues that we would not accept as fatal in the community, so why are they fatal in prisons?"

Ms Crellin said governments, public bodies, and institutions, including private prisons, are too "easily" able to dodge coronial recommendations and avoid reform.

She said five Indigenous people have died in custody or during police operations in the last three weeks.

"We want to see greater accountability," Ms Crellin said.

"In Danny Whitton's inquest, there were some recommendations made, and we want a database that is open to the public to ensure they are actually actioned."

Magistrate Truscott acknowledged changes have already been made at Junee Correctional Centre, but made recommendations for the Geo Group, Justice Health and Corrective Services.

The ALS also called for funding to be increased to the Coroner's Court, reducing extensive delays between deaths and inquests.

"Danny Whitton's family were made to wait six years for their day in court, only to watch several witnesses say they couldn't recall what happened in Danny's final days," she said.

"It was another six years of their lives in which they didn't have answers and couldn't reach any kind of closure. They will never have many of the answers they sought."

Ms Crellin said the families they work with are resilient, but the coronial process re-traumatises many people rather than offering healing.

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