An Aboriginal prisoner was left unsupervised in his cell despite being assessed as requiring urgent psychiatric care and complaining of chest pain, an inquest has heard.
He died after a suicide attempt, which triggered a heart attack.
Deputy State Coroner Anthony Schapel is investigating the 68-year-old's death while on remand at Yatala Labour Prison.
His family has asked that he not be named for cultural reasons.
He had been in custody at Port Augusta Prison for four weeks after being refused bail on an assault charge.
The court heard he was transferred to Yatala for an urgent psychiatric assessment after attempting to self harm because psychiatric appointments were not regularly available at the Port Augusta Prison.
In her opening address, counsel assisting the coroner Kathryn Waite said the man was not kept under camera surveillance or in a "canvas cell" for his own safety as recommended by the prison doctor.
Instead, he was placed in a normal cell with another inmate, who at the time of his death had been escorted from the cell for a parole board appointment.
Ms Waite questioned why the level of surveillance the inmate received at Port Augusta Prison did not continue when he was transferred to Yatala.
"Was there a communication issue between the two prisons which led to a failure to maintain observation and support?" she asked.
"If putting someone in a double-up cell is deemed an appropriate protective measure against self harm then is it ever appropriate to leave a double-up prisoner alone if their cellmate has been taken somewhere?"
Death happened during prison lockdown
The inquest heard the man's psychiatric assessment was cancelled because the prison was sent into lockdown and a corrections officer was not available to escort him to the appointment.
It was during the lockdown that he attempted suicide.
Ms Waite questioned whether there was a failure to provide the prisoner with psychiatric assistance in a timely manner, especially given his transfer from Port Augusta had been deemed urgent.
"Was he appropriately triaged at the Yatala Labour Prison?" she asked.
"Questions of appropriateness of mental health care may also lead to questions regarding the psychiatric service that prisoners receive generally."
The court heard in the lead up to his death, he asked several times if he could go to hospital because he was having chest pains.
Ms Waite said a doctor at the prison's health clinic conducted an electrocardiogram (ECG test) on him but he was cleared to return to his cell.
"Was there a failure to recognise the symptoms he was describing?" she asked.
"Should have [he] been transferred to hospital? Was the chest pain protocol complied with?
"This court will be invited to consider that if [he] had been properly evaluated for a heart-related incident then he would have never been put in lockdown, let alone, by himself."
A number of staff have been called to give evidence at the inquest over the next five days.
