Seth Yeeda's family wants answers about the death in custody of the WA teenager who had a long history of chronic heart problems.
Mr Yeeda was only 19 when he died at the West Kimberley Regional Prison on 3 May 2018.
His mother Marlene Carlton said it has been heartbreaking to sit in court and listen to the evidence.
“They failed in their duty of care. They took him right out of the family and they took that duty of care from us," she told NITV News.
"They put him in the justice system where they failed him.”
The WA Coroner's Court heard Mr Yeeda had a significant medical history, having been diagnosed with Acute Rheumatic Fever when he was 9 years old.
While he was in custody, a medical alert was placed on his prison records and he was assessed as being 'not fit for sports or strenuous activity'.
Mr Yeeda received monthly bicillin injections and on 5 December 2017, he was referred to an urgent cardiology appointment.
However despite that referral, Mr Yeeda was not added to the visiting cardiologists list and missed the appointment.
A second referral was made in January 2018, however the court heard there is no evidence the referral was ever sent to, or received by the service provider.
The court also heard that Mr Yeeda's medical alert that he was 'not fit for sport' was changed on 12 April 2018 by a nurse at the West Kimberley Regional Prison. No reference or reason was recorded.
Seth Yeeda was only 19 when he died at the West Kimberley Regional Prison Source: Supplied
On the day he died, Mr Yeeda had been playing basketball with other inmates. A short time later he collapsed to the floor.
Prison officers responded and began CPR before he was taken to the Derby Regional Hospital where he later died.
Sergeant Assisting Alan Becker told the court the inquest would consider whether the medical care provided to Mr Yeeda was 'commensurate with community standards'.
Mr Yeeda's mother Marlene Carlton said the prison system was aware of her son’s health problems.
“They knew about his health problem from the age of 13 from being in Banksia, in and out till he was 18. So they can’t say they did not know about his heart condition, they did know. And they failed to do something.
“The prison system, the justice system and the health system all failed him. They just didn’t do their job.
Marlene’s eldest sister Helen Carlton says her nephew came from a good home.
“We are good people. The local people know us in the town and where he come from.
“Teenagers get in to mischief, that’s how he ended up in the system. Banksia correctional had him in and out since he was 13 years old.
"We tried to support him as a family and did as much as we could do to keep him out of that situation.”
Ms Carlton said she was one of the last people to speak to her nephew.
Marlene Carlton says the prison system and health system failed her son Source: Kearyn Cox
“He was telling me when I come out I want to start a family. He knew what he done was wrong, he was young but he was growing up. He wanted to be somebody. He didn’t even have the chance to have it.”
She said she stressed to him the importance of his medications.
“I know I stressed for the right reasons, I knew when he came into this world that he was very sick. We knew that he was going to have to have medication until he was 40 years old.
“There were warnings there to protect him. Health staff were supposed to look at them warnings and work on them but they actually removed them safeguards and removed all mention of his heart condition.”
Marlene’s partner Daniel Taylor said the family wants answers.
“There’s been no justice, they have ticked the boxes and they have gone through the motions but there is no justice.
“We are going to have to wait now until the coroner gives the findings.”
“There is consequences to the actions we do, we end up in jail and we are held responsible and punished for that. Where are the consequences for their actions? I think that is all we need.”
Marlene says she will receive the Coroner's findings over the phone as she has to fly back to her home in Kununurra.
The inquest is expected to resume later this month.
