Nathan Reynolds death in custody coronial inquest gives recommendations

NSW’s prison system failed an Aboriginal man when a slow and chaotic response to his asthma attack “deprived him” of any chance to survive, the coroner has ruled.

NSW’s prison system failed Aboriginal man Nathan Reynolds when a slow and chaotic response to his asthma attack “deprived him” of any chance to survive, the coroner has ruled.

Chronic asthmatic Mr Reynolds was in his cell at the Outer Metro Correctional Centre at Berkshire Park when he began struggling for breath late on August 31, 2018.

He called for help at 11:27pm, and seven minutes later his cellmate called the guards again and urged them to hurry.

The guards took 11 minutes to reach H Wing, where Mr Reynolds was located, and didn’t bring a nurse. CCTV appeared to show them walking without urgency, the court heard.

“He was a man begging for help with his eyes and he couldn’t say a word … What little breath he had was just gasping for help,” one inmate told the court in tears.

Nathan Reynolds was in his cell at the Outer Metro Correctional Centre at Berkshire Park when he began struggling for breath.

It would take a night nurse 22 minutes to arrive at the scene.

“To have any chance of survival, he needed aid that only paramedics with advanced life support training and equipment can deliver, namely tracheal intubation and ventilation,” an expert would conclude.

The court heard the paramedics needed to be summoned upon the first calls for help from Mr Reynolds.

Instead he died on the floor of the H Wing.

Deputy State Coroner Elizabeth Ryan slammed the “confused, uncoordinated and unreasonably delayed” response by prison authorities.

She said the delay “deprived Nathan of the small chance he had of surviving his acute asthma attack”.

The coroner concluded natural bronchial asthma was Mr Reynolds’ cause of death, but “deficiencies” in both the immediate response and the long term management of his condition were contributing factors.

Mr Reynolds’ family and friends listened to profoundly distressing evidence each and every day of the inquest with “dignity and courage”, the coroner said.

“I know you grieve his loss and miss him deeply,” she said, thanking them.

The coroner heard one source of grievance was the night nurse shot Mr Reynolds up with a drug designed to reverse opioid overdoses — that was despite no evidence he had taken any illicit substances.

All calls for help had been about his breathing problems.

More than a dozen supporters had turned up at the coroner’s court to hear the findings on Thursday — some wore shirts with Mr Reynolds’ face, others with the Aboriginal flag — almost all wore black.

Outside the court the Aboriginal flag was strung across the entrance by one solemn supporter.

Reynolds was into the final days of a nine-month domestic violence sentence when he died.

Magistrate Ryan said his status as a First Nations man added another troubling dimension to his case.

She noted that it had been 30 years since the royal commission into deaths in custody concluded Aboriginal people are overrepresented behind bars.

Two more indigenous deaths in NSW custody were reported just this week, she said.

Two First Nations people, this week, have died in custody

The coroner’s court issued four recommendations about the handling of asthma, rostering, and serious health events to Corrective Services NSW.

Seven more recommendations for Justice Health, which runs the prison medical system, include that they look for insights from indigenous health care services.