The family of a mentally ill Aboriginal man who took his own life in prison say his death could have been avoided with appropriate care and better safety measures in cells.
Timothy Garner died while he was being held at Sydney's Silverwater jail on July 7, 2018.
He was on remand after being charged with robbery and possession of a prohibited drug three months earlier.
A coronial inquest heard the 30-year-old father had been diagnosed with bipolar disorder and schizophrenia and was being seen by a specialist team to assess his risk of self-harm in the lead-up to his death.
In the week before he died, a psychiatrist recommended Mr Garner be transferred to a mental health facility.
But five days before his death, he was removed from the waitlist and cleared from the "risk-intervention team's" assessment after his condition was deemed to have improved.
Delivering his findings on Thursday, Deputy State Coroner Derek Lee said it would have been more appropriate for Mr Garner to remain under the team's management after reviews carried out in June 2018.
"It would have allowed for Tim to be monitored and reviewed regularly and for any ongoing interventions to be facilitated," he said.
But Mr Lee found it was not possible to determine if ongoing risk intervention would have been "likely to materially alter subsequent events".
He said the time taken for Mr Garner to be reviewed by psychiatrists in May and June 2018 "did not conform with defined time frames" and he was not adequately reviewed in the five-day period before his death.
"He was not in fact reviewed at all," Mr Lee said.
The coroner also noted the prison staff's communication with Mr Garner's family was a matter of "central importance".
"His mother continually called the prison to express her concern that Tim was acutely unwell, not taking his medication and not being treated properly," Mr Lee said.
Outside the court, Michelle Garner said her son's death had "broken" the family.
"Tim's death could have been avoided if he'd been given the appropriate health care and he'd still be with us today," she said.
"The last time I saw Tim alive, I told prison staff he needed to see a doctor, he needed to be medicated, but I wasn't kept informed about my son's condition."
Ms Garner said she regularly called the prison "begging them to help him", but no one returned her call.
"Prisons are full of people with mental illness ... there needs to be much better support," she said.
The coroner recommended all inmates under risk assessment be housed in cells without hanging or ligature points by the end of 2024.
Emma Parker from the Aboriginal Legal Service said advice from a 1991 royal commission into Aboriginal deaths in custody for their removal had gone unheeded.
"Tim Garner tragically died 27 years after that recommendation was handed down," she said.
The coroner also recommended "refresher training" for prison staff on risk intervention teams take place every five years after hearing some of those tasked with Mr Garner's care had not completed mandatory training.
But Ms Parker said Mr Garner should have been in a hospital, and his repeated self-harm attempts and mental illness were poorly understood by prison staff.
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beyondblue 1300 22 4636
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Aboriginal Counselling Services 0410 539 905
