After three days of harrowing evidence detailing the final moments of Bernard Hector's life, the 31-year-old's family say they feel the coroner has heard their concerns about his treatment in prison.
Aboriginal and Torres Strait Islander readers are advised that this article contains the name of an Indigenous man who has died, used with the permission of his family.
Mr Hector died by suicide at the Darwin Correctional Centre in August 2021, after being on remand for about six weeks.
His death in custody triggered a mandatory coronial inquest examining his care, supervision, and treatment in prison.
As the details of his death were put to the coroner this week, his mother Colleen Long, aunt Amy Johnson and brother Aaron Hector, sat in the front row of the courtroom.
Outside, they told reporters it had been a tough three days.
"It hurts, but we have to sit through it," Ms Johnson said. "We don't want [a suicide] to happen again."
Coroner Elisabeth Armitage heard Mr Hector had been playing with a homemade Ouija board, claimed he had "sold his soul to the devil" and, to fellow prisoners, had become sad, worried and quiet prior to his death.
But representatives from the Northern Territory's health and corrections departments told the inquest, prison staff had no idea Mr Hector's mental health had taken a turn.
"There are several possibilities … one is that Mr Hector didn't want people to know," Ruth Derkenne from NT Health said.
"Time and time again, people will commit suicide and friends, family and co-workers will be completely shocked."
"The only person we've spoken to in all of these enquiries who did detect there was a change in Mr Hector was his friends."
The coroner earlier heard from two of Mr Hector's fellow inmates who had noticed his behaviour changed and both said they did not raise an alarm with staff.
'Monitoring period' for mental health not recommended
Mr Hector had been deemed "at risk" of self-harm when he was remanded in custody, but his status was removed 24 hours later. After a health assessment, he was referred for drug and alcohol counselling.
Dr Derkenne said the assessment was comprehensive and she stood by the decision during an extensive, and at times combative, cross-examination by his family's barrister, John Lawrence SC.
"The assessment of the people who are highly trained is that they did not perceive he needed ongoing assessment by a forensic mental health team," Dr Durkenne said.
"And we would still say that."
For six weeks, the prisoner lived in sector six of the Darwin Correctional Centre, where, the coroner heard, a series of COVID-related interruptions meant he was unable to make every appointment set for him.
His family's barrister suggested a "monitoring period" should have been in place after Mr Hector's at-risk status was lifted.
Dr Derkenne said her research showed longer-term "safety plans" were a better option.
"We could say they need to be monitored for seven days or 14 days and throughout that period of time things are OK … and then on day 15 … something bad happens to them … and they're no longer being monitored," Dr Derkenne said.
The coroner heard the current recommendation was for a plan to be developed for people who had a history of mental health concerns, connecting them to support services.
She also said a "more reliable system" should be in place to encourage prisoners to flag concerning behaviour with staff.
"We're here to reflect on what happened to Mr Hector, recognise what the gaps are and introduce something that's going to try and stop it from happening again," Dr Derkenne said.
The inquest was adjourned until February 7, when further witnesses will be called to give evidence.
