Handing down his findings in the inquest into the death of Alf Eades on Monday, WA Coroner Michael Jenkin was highly critical of the lack of supervision and care that Mr Eades received while in custody in Hakea Prison.

Mr Eades, a 46-year-old Noongar man, was fatally punched, kicked and stomped on multiple times by other inmates as he ate his dinner alone in his cell at Hakea Prison on February 26, 2019.

Coroner Jenkin found Mr Eades, who had a major mental illness, was a vulnerable prisoner.

Mr Eades was previously diagnosed with bipolar affective disorder and schizophrenia which required him to take medication and would often lead to emotional outbursts.

Mr Eades' family have consistently maintained that he was failed by the WA government and the Department of Justice failed him.

Coroner Jenkins found that "the standard of supervision and care Alf received whilst he was incarcerated at Hakea was unacceptable".

His Honour was critical of the unprofessional and inappropriate way in which prison officers responded to the numerous cell calls made by Mr Eades seeking their assistance and requesting that he be moved out of his cell for his safety.

The coroner concluded that had the "…Cell Call[s] been responded to (as it obviously should have been), there is a possibility that Alf may have been transferred off Unit 9 to another unit, (or to the Crisis Care Unit), meaning he may not have been assaulted in the manner that he was".

National Justice Project acted for Robert Eades, Mr Eades' brother at the inquest.

Robert Eades asked: "Why has this happened to our brother and why does it continue to happen to other vulnerable people with mental health issues?"

National Justice Project chief executive George Newhouse said: "This is a devastating loss of life, and we particularly feel for Mr Eades' orphaned children and the grieving family he leaves behind."

"Prisoners with mental health conditions often fall prey to violence or face serious risk of self-harm in Australian prisons. There needs to be systemic change to ensure that vulnerable inmates, like Mr Eades, are protected in WA and all other prisons," Mr Newhouse said.

His Honour has handed down some powerful findings and recommendations, most of which have already been accepted by Hakea Prison and the WA Department of Justice, however the NJP will continue to fight for meaningful and culturally appropriate healthcare in prisons."

A WA Department of Justice spokesperson told National Indigenous Times the Department "will carefully consider the Coroner's findings and recommendations".

"The Department has already taken some immediate action in regard to Recommendations 1, 2 and 3 by reinforcing and enhancing protocols, and making clear the Corrective Services Commissioner's expectations for responding to cell calls," they said.

More than 500 Aboriginal and Torres Strait Islander people have died in custody in Australia since the Royal Commission into Aboriginal Deaths in Custody brought down its findings in 1991, making more than 300 recommendations, many of which remain unimplemented today.