The Coronial Inquiry into the death of Indigenous man Nathan Reynolds found that he died on his cell floor due to “confused, unreasonably delayed, and uncoordinated” medical response by prison staff.
**This article contains images of a First Nations person who has died. The article also discusses the nature of his death**
Deputy State Coroner Elizabeth Ryan handed down her findings yesterday into the death of the 36-year-old Anaiwan and Dunghutti man.
Nathan Reynolds died on the concrete floor of his prison cell from bronchial asthma in 2018. He was due for release one week later.
Ms Ryan said that on the night of Mr Reynolds’s death he required emergency treatment but the response he received “fell well short of this”.
“It was confused, uncoordinated and unreasonably delayed,” Ms Ryan said.
“The delay deprived Nathan of at least some chance of surviving his acute asthma attack.
“These failures were due both to numerous system deficiencies and to individual errors of judgment.”
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A preventable death
The coroner found Mr Reynolds died of “natural causes”. However, deficiencies in the management of his severe asthma exacerbated those conditions.
The family of Mr Reynolds have been fighting for justice since the day he passed in 2018.
One of his sisters, Taleah Reynolds, said that she was furious that her brother’s death was preventable.
“Several times he went to the prison clinic and said he wasn’t feeling well, it was never any secret that Nathan was asthmatic.
Ms Reynolds said her brother “would not have died [from this asthma attack] if he weren’t in prison”.
“This can’t just be treated as an accident — it must be recognised as a huge institutional failing and people must be held responsible,” she said.
A call for help
Nathan Reynolds was struggling to breathe when he urgently called for help at 11:27pm on August 31, 2018.
Prison guards took 11 minutes to respond. Prison staff called an ambulance 21 minutes after he signalled for help, and the registered nurse on duty arrived 23 minutes after he signalled for help.
By that time, Mr Reynolds was unresponsive.
Paramedics declared Mr Reynolds dead at 12:44am, about half an hour after the ambulance arrived on the scene.
Ms Ryan said the failures went beyond what happened on the night of the emergency, saying the health care he received since entering custody was “inadequate”.
“It failed to reduce his risk for a fatal asthma attack, it did not comply with established treatment for the management of severe asthma,” she said.
“These failings significantly increased Nathan’s risk for the fatal attack.”
The fight for justice
With over 440 First Nations deaths in custody since the Royal Commission, the fight for justice is far from over. Three First Nations people have died in custody in the last week alone.
Mr Reynolds’s sisters Taleah and Makayla said they would never give up on getting justice for their brother.
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