Junior Fenika had only one way of communicating with the outside world as he slowly bled to death in his NSW prison cell over several hours.
But no one came when the mentally ill 24-year-old twice pressed an intercom button saying he'd "slashed up".
Mr Fenika was pronounced dead in his cell at Goulburn High Risk Management Correctional Centre more than 11 hours later, on the morning of September 12, 2015.
The inmate had finished his sentence for violence and property offences a month earlier, but was still being detained ahead of his deportation to New Zealand.
At Glebe Coroners Court on Friday, deputy state coroner Teresa O'Sullivan found his death would likely have been prevented if prison staff responded appropriately to his intercom calls at 9.17pm and 9.23pm.
The officer who received his "knock-up" calls gave evidence he couldn't make out what Mr Fenika was saying, and he thought he heard him the inmate ask "where's my stuff?"
He didn't reverse call Mr Fenika to clarify even though it was possible to do so, the coroner said.
Two other officers who were alerted to the calls looked at Mr Fenika's cell from an officer's station without actually approaching it and without being able to see inside.
The coroner said they also could have reverse called Mr Fenika but didn't.
"This was the obvious thing to do because no one knew why the knock-up call had been made and it was the easiest way to contact Junior," she said.
"It was a clear failure by the two officers to take an obvious step and is deserving of censure."
By this stage, blood had appeared at the bottom of Mr Fenika's door to a rear yard and water was also beginning to flow from the rear of his cell.
Officers in the night and early morning were shown walking over the mixture of blood and water without paying it any attention.
The inquest heard Mr Fenika's mental health had worsened over time and his continued detention pending deportation had markedly increased his stress.
He moved from New Zealand with his family as a young child in 1996, but had never taken out citizenship.
Ms O'Sullivan said it was commendable that many of her recommendations - canvassing mental health care in the prison, the knock-up system and family visits - had already been or were in the process of being implemented.
The recommendations included a review to determine if there were enough beds for mentally ill patients in the NSW correctional system.
Her findings on Friday were welcomed by Mr Fenika's family, who attended every day of his inquest in Sydney and Goulburn and felt they had received justice.
"He was a loving, caring brother, and he was a good kid. He was just with the wrong crowd but he was brought up by a Christian family," his emotional sister Sharon Togatuki told reporters outside court.
"All that we wanted was just justice for my family, you know. It's not gonna bring Junior back but the memories are still in our hearts."
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