Lathan Brown was a warm and creative young man with a "fighting spirit", one of eight siblings who shared deep bonds with a big extended family.
That family is now living with "endless pain", having missed saying their final goodbyes by just 10 minutes after Mr Brown's sudden death on January 6, 2024.
The 28-year-old, a proud Kamilaroi and Barkandji man, was on remand in Wellington Correctional Centre, in central western NSW, when he collapsed in his cell that afternoon.
Deputy State Coroner Stuart Devine on Thursday found Mr Brown's unexpected death from heart arrhythmia was not preventable.
But Mr Devine highlighted several gaps in NSW Corrective Services officers' communication with the Brown family, which meant they were not at his bedside when he died in hospital.
Paramedics took Mr Brown to Wellington hospital just before 5pm and a prison officer called his family to inform them of his dire condition, the inquest was told.
One of Mr Brown's uncles called the officer for an update at 6pm and was told he would be transferred to the larger hospital at nearby Dubbo.
Mr Brown's father Michael then drove 150km from Orange to Dubbo to be with his son, but medical teams had already arranged for him to be flown by helicopter to Orange Health Service.
Resuscitation efforts were stopped soon after Mr Brown arrived at the Orange facility and he died at 11.15pm.
His father got to the hospital at 11.25pm.
"Lathan passed away without his family being with him and this is still deeply horrifying and upsetting to me," Michael Brown said in a statement, issued through the NSW Aboriginal Legal Service.
"We didn't get a chance to say goodbye.
"There was time wasted where we could have spent time with him and we can never get that time back."
The coroner made several recommendations, including that NSW Corrective Services policies be amended, requiring a senior officer to closely liaise with families in the event of an inmate's imminent death.
Mr Devine said Mr Brown's case should also be considered in the context of First Nations deaths in custody.
"Aboriginal and Torres Strait Islander people are notoriously over-represented within NSW's prison population and consequently there are a disturbing number of Aboriginal deaths in custody," he said.
"There can be no argument that First Nations people continue to experience significant disadvantage and poorer health outcomes across the board compared to the broader population."
The Brown family showed strength, fortitude and "quiet dignity" while demanding answers for their son, grandson and brother, Mr Devine said.
"It is obvious to me they wanted to understand the full circumstances of Lathan's death, but also wanted to be part of any positive change that could arise from his passing."
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