An Indigenous man in custody had a mental health episode on a Sunday, received culturally unsafe care for a day, and was discharged from the clinic on the Tuesday.
Three weeks later, he was found dead in his cell.
A NSW coronial report released on Friday found a Bunjalung and Yaegal man had died by his own hand at the Shortland Correctional Centre in NSW in November 2021.
The 26-year-old , known as RRC, told police he "didn't want to live any more" shortly after he was taken into custody because his apprehended domestic violence order would prevent him from seeing his beloved children.
On October 17, 2021 he self-harmed and was placed into a cell for continuous observation.
He was reviewed by a mental health panel the next day and discharged from the Risk Intervention Team's management plan on October 19 before moving into a cell with his cousin, who said he seemed jovial in the days after his assessment.
“RRC was the man with the biggest smile on his face, but clearly it was masking his great sadness," he told the coroner.
"I say this on reflection. I had no idea that he was suffering emotionally. RRC, I guess like a lot of young Aboriginal men, can mask their true feelings.”
RRC later requested to be placed in a single cell because some had become available. His cousin felt that, in hindsight, they should have stayed in a cell together.
On November 1, a psychologist noted RRC was future-focused towards re-establishing contact with his children.
Five days later, he was found dead.
An independent review by associate professor Marlene Longbottom, included in the coronial report, found the mental health services lacked cultural competence and were not "culturally safe".
The Western tools used to assess mental health did not factor the cultural needs of Aboriginal and Torres Strait Islander people and the power inequities between RRC and those responsible for his care prevented him from speaking openly about his mental state.
Ms Longbottom also said Indigenous Australians place strong emphasis on relationships with friends and family, and noted RRC struggled with his disconnection.
Deputy State Coroner Carmel Forbes' findings also revealed he had been discharged without a plan for future care and cell placement.
"In hindsight, more could have been done to put in place protective measures for RRC when he returned to the wing and to continue his care and treatment."
Ms Forbes recommended Correctional Services NSW review the discharge process and assess whether it effectively reduces risk of further self-harm, consider the importance of continued care and whether alternative mental health models could be used, and consult the Aboriginal Medical Research Council for advice.
President of the NSW Bar Association Gabrielle Bashir SC welcomed the recommendations but called on the government to do more.
"This tragic death of another First Nations person in custody only emphasises the crucial need for the NSW government to implement the many practical reforms already recommended in order to make essential and long overdue reforms to our justice system," she said in a statement.
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