Budjiti and Murrawarri man Douglas "Mootijah" Shillingsworth died of a middle ear infection, known as otitis media, at the age of 44 on February 15, 2018 while incarcerated at the Silverwater prison complex in Sydney.
On Friday, coroner Joan Baptie found that Shillingsworth's chronic ear problems could have been easily picked up while he was in custody if proper procedures had been put in place by the Justice Health and Forensic Mental Health Network.
"Mootijah's death was the result of the systemic failures prevalent in the public health system, the custodial health system in NSW and the lack of identification and appreciation of this silent killer, otitis media," she wrote.
Among other health issues, Shillingsworth experienced recurring middle ear infections throughout his life, resulting in impaired hearing, the coroner found.
These infections are found at higher rates amongst Aboriginal and Torres Strait Islanders.
He was in jail 13 times from 1997 to 2017. At the time of his final arrest in March 2017, his ear issues had not been identified as a "significant health issue," Ms Baptie said.
The Justice Health Network confirmed it did not provide specific screening to its nurses to treat patients with impaired hearing. It also admitted that it did not mandate chronic disease screening for all Aboriginals and Torres Strait Islanders.
Shillingsworth died at Westmead Hospital after a severe infection of an abscess caused by the ear infection resulted in a neurological injury.
At the time, he was in custody and awaiting sentence after being arrested for assault and resisting police in March 2017.
A statement from his family outlined the hurt, anguish, disbelief and heartbreak that his death had created.
"Although there will be no justice, we sincerely hope that his death in custody will bring about change. His death has left his family devastated to the core in all forms of incapacity," they wrote.
Ms Baptie made four recommendations to the NSW Ministry of Health and the Justice Health Network included reforming practices regarding ear disease and hearing difficulties.
The network was also encouraged to explore partnerships with Aboriginal Community Controlled Health Organisations to provide culturally appropriate healthcare in custody, and to trial access to Medicare for Aboriginal inmates.
Outside the Coroners Court in Lidcombe, Aboriginal Legal Service solicitor Jeremy Styles said this was another addition to the incomplete ledger of black deaths in custody.
"At the bottom of this, this was a simple medical tragedy - a death of a man, a brother, a son, a father which should not have happened," he said.
Mr Styles said he would like to see the very large structural changes recommended by the coroner put into action, especially the federal government allowing access to Medicare for Aboriginal people in jail.
In a statement, the Justice Health Network said it was deeply saddened by Shillingworth's death, acknowledging he did not receive the required care.
The network said it would carefully consider the coroner's findings, and would improve its healthcare services including by signing a statement of commitment to Aboriginal health.
"Justice Health is committed to implement changes which will more readily identify, treat and manage middle ear infection in the indigenous prison population," it said.
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