An inquest into the death of a First Nations man who died after falling eight metres while trying to escape custody has heard that a "real lack of humanity" by correctional staff contributed to the man's avoidable death.
NSW deputy state coroner Elaine Truscott heard that Wiradjuri man Bailey Mackander was taken to hospital in November 2019 after he reported swallowing batteries and razor blades.
Mr Mackander, 20, had been isolated in an assessment or 'safe' cell at Kariong Correctional Centre, where he was reportedly heard screaming in distress for two days.
A decision was made to take him to Gosford Hospital.
The Port Stephens man died after escaping custody, climbing over a concrete barrier and falling 8 metres.
Treatment questioned
The inquest heard the cell Mr Mackander was placed in was deemed unsafe for him as he suffered from anxiety.
Lawyer Georgia Lewer, who represented Mr Mackander's father and stepmother, was scathing in her closing submission.
"On numerous occasions, Bailey was dealt with in a contemptuous manner," she said.
"There was gross disregard for his deteriorating mental state; guards stepped over him and entirely ignored him in the cell.
"His request for dinner is ignored, a request to turn off the TV so he can sleep is ignored.
Claims of 'crying wolf'
Paperwork given to treating doctors at Gosford Hospital by guards stated that Mr Mackander had a habit of "crying wolf".
The inquest heard the language was inappropriate and had the capacity to undermine [hospital] treatment Mr Mackander might have received.
In his closing submission, Bill de Mars, the lawyer for Mr Mackander's mother Tracey, said that following Mr Mackander's treatment, panic set in which resulted in the deceased scaling the ambulance bay wall and falling to his death.
"We find a key motivating factor in the action Bailey took was the fear and anxiety of returning to the observation cell based on his previous distress," Mr de Mars said.
The lawyer for Bailey's father, David, and step-mother, Melissa, reached the same conclusion.
"With the horror of the conditions he thought confronted him in the assessment cell, he may have felt so distressed at the thought of returning," Ms Lewer said.
Mental healthcare lacking
The inquest heard Mr Mackander had anxiety and mental health issues for at least nine weeks prior to his death.
The inquest heard he was meant to have weekly appointments with a psychologist, but that had not occurred.
The lawyer for a treating nurse said in her submission that "there was tremendous pressure placed on her client and she didn't have specific mental health training".
The inquest heard Mr Mackander had not had a medication assessment or a comprehensive mental health assessment in the lead-up to his death.
Call for 'fundamental change'
Mr Mackander's family spoke of a kind, loving boy, who sought rehabilitation, despite no treatment places being available.
"The family wish me to emphasise that Bailey was gentle and he was kind. He was still very young, with limited life or jail experience, struggling to find his place in the world," Ms Lewer said.
"It is a problem that requires wholesale political and community support, and fundamental change."
Coroner Truscott previously described Mr Mackander as "a beautiful boy in a not-so-beautiful system".
On Tuesday, she reached out to the family again, noting that three days had past since the second anniversary of Mr Mackander's death.
Coroner Truscott will hand down her findings on December 15.
