Safety checks on an Indigenous woman in custody did not meet the required standard in the hours before she was found dead, a Queensland coronial inquest has heard.
The Coroners Court on Wednesday held the third day of joint hearings into the death of Shiralee Deanne Tilberoo, known as Aunty Sherry, 49, at the Brisbane City Watch House on September 10, 2020.
The inquest is also looking into the death of another woman, Vlasta Wylucki, at Southport Watch House in 2018.
Aunty Sherry was a matriarch of the Birri Gubba people and her death in custody from a brain aneurysm prompted Black Lives Matter protests across Brisbane in the days that followed.
Watch House officer Debra Haigh was on duty from 10pm on September 9, including the hours leading up to Aunty Sherry being found dead in her cell at 6.20am.
Ms Haigh testified that she completed nine inspections of Aunty Sherry's cell during the night.
"She was lying on her left side facing her cellmate. She had a foot out of the blanket and all I could see was the top of her head," Ms Haigh said.
The inquest heard it was written policy for officers to confirm that a prisoner was alive and breathing during a cell check.
Ms Haigh said she usually took a torch with her to help see into the dimly lit cells and confirm that a prisoner's chest was rising and falling but on that night she "forgot" to bring her personal torch.
"They had some very old Maglites or cheap Woolworths torches. That's why I bought my own," Ms Haigh said.
Ms Haigh agreed with Counsel Assisting Sarah Lane that she could not see properly into the cell without a torch but she could have used the intercom, tapped on the glass or called for another officer to accompany her into the cell in order to check on Aunty Sherry.
The inquest heard the Queensland Police ethical standards command found Ms Haigh "did not do (her) cell checks to the required standard" on the night of Aunty Sherry's death and she was subject to disciplinary measures.
Neurologist Christian Gericke previously told the inquest the watch house likely could not have done anything to save Aunty Sherry from fatal bleeding on the brain after her aneurysm ruptured.
Ms Haigh said she was suspended for six months on base pay and without shift allowances, then transferred to the property department for 10 months. She then returned to the watch house with a requirement to complete three hours of online training and review the operating procedures.
"It wasn't laziness. I might not have been in the right headspace after being on the wing for two nights in a row ... I now spend a lot more time at each cell (when doing prisoner checks)," Ms Haigh said.
Ms Haigh said spending night shifts checking cells on the wing was a less desirable job as it was dark and lonely and staff had to respond to fights or suicide attempts.
Ms Haigh confirmed to Coroner Stephanie Gallagher that, to her knowledge, she had not been audited for her cell check compliance since returning to the watch house.
