Please note: this story contains reference to someone who has died.


The coronial inquiry into a 2018 death in custody has found prison staff’s “unreasonably delayed” response to a fatal asthma attack contributed to the death of an inmate at Francis Greenway Correction Complex.

Aboriginal man Nathan Reynolds was serving a four-month sentence at John Morony Correctional Centre, now Francis Greenway Correctional Complex in Windsor, New South Wales. In August 2018, one week before his release, the 36-year-old father died from a severe asthma attack.

The NSW Coroner found Reynolds was deprived of “at least some chance” of survival due to the “unreasonably delayed” response by prison and health staff.

Despite this, the coroner found his death to be by natural causes that were partly impacted by deficiencies in the management of his pre-existing medical condition.

“Nathan’s medical crisis on the night of 31 August required an emergency response. But the response he received fell well short of this. It was confused, uncoordinated and unreasonably delayed,” said Deputy State Coroner Elizabeth Ryan.

“The delay deprived Nathan of at least some chance of surviving his acute asthma attack. These failures were due both to numerous system deficiencies and to individual errors of judgement.”

In October, the inquest heard that Reynolds had called for assistance at 11.27pm but staff arrived 12 minutes after the call. When questioned regarding the reason for delay, prison officer Matthew Fawzy said he could not “think of anything”.

Reynolds’ family gathered outside of the NSW Coroner’s Court on Thursday morning. Reynolds’ sister Taleah Reynolds addressed the media.

“One officer when asked what he would do differently on the day of my brother’s death said, ‘take a sickie’. This was disgusting for our family to hear,” she said.

“Today I want to remember our brother, Nathan Reynolds. He is one of more than 440 Aboriginal people who have died in custody in the last 30 years. But he is not just a statistic.

“Losing him has left a hole in our lives and we miss him every single day.”

In a statement, the family called for accountability from NSW Justice Health and NSW Corrective Services.

“It’s soul-crushing knowing that at just 36-years-old, Nathan died on the cold floor of a prison, separated from his family and loved ones. Words can’t describe our pain,” they said.

“We are also angry because Nathan’s death was preventable … This can’t just be treated as an accident — it must be recognised as a huge institutional failing and people must be held responsible.”

The family submitted a number of requested recommendations to the Coroner which include building awareness in the prison system of better health management, particularly around asthma.

“In the case of Nathan’s death, we see a prison culture that was sceptical of the medical needs of residents,” said Aboriginal Legal Service NSW/ACT CEO, Karly Warner.

“While processes existed to manage chronic health conditions, these were hardly worth the paper they were written on, as staff were either unaware of them or failed to follow them.”

Warner notes that during his time in prison, Reynold’s health declined and he began to show signs of an oncoming acute asthma attack.

“He was cut off from community health care and entirely in the hands of Corrective Services NSW and Justice Health, who failed in their responsibilities to him,” she said.

“That failure cost Nathan his life. This is why we say that Aboriginal people’s lives are put at risk when they are sent to prison.”

Reynolds is one of almost 500 Aboriginal people who have died in custody since the Royal Commission into Aboriginal Deaths in Custody. In March alone, three Aboriginal people have died in custody.

A month shy of the Commission report’s 30th anniversary, many are still waiting for the recommendations to be implemented.

By Rachael Knowles