It took 17 minutes for an Aboriginal prisoner to be pulled out of his cell and given medical treatment after he became unconscious.
But it was too late. By the time paramedics got to Joshua Kerr, he was dead.
Several corrections and medical staff had been watching the 32-year-old behaving erratically on CCTV in the hours before his death.
He was heard saying "I'm dying" over intercom, and seen by prison supervisors trying to drink from the shower and toilet after he was not given water or food.
Not one of these people intervened.
Victorian coroner David Ryan is investigating the Yorta Yorta and Gunnaikurnai man's death, and why prison staff did not get him medical treatment sooner.
An inquest into the August 10, 2022, death began on Monday.
Counsel assisting Rachel Ellyard said Kerr had been undergoing quarantine in his cell due to COVID-19 protocols, after leaving prison to go to a funeral in the days before he died.
He had been on remand in prison for more than a year, while awaiting trial.
Hours before he died, Kerr was taken to hospital after lighting a fire inside his cell and burning his hand.
He told a nurse he had been paranoid because he was using methamphetamine.
Kerr was taken to St Vincent's Hospital for treatment, but Tactical Operations Group police decided to take him back to prison before he was formally discharged.
They removed him from the hospital before his wounds could be re-dressed by a specialist.
Kerr was escorted to his cell by the tactical officers about 4.45pm and the following hours were captured on CCTV from his cell, which will not be publicly released.
Ms Ellyard said it was unclear why a directive was given that Kerr's cell could only be opened if tactical officers were present, "as if it was a blanket, enforceable rule" for the rest of the evening.
"It's also not clear whether those giving the directive intended it to have a complete broad effect, or whether anyone took steps to challenge it because they thought it was not right," she said.
She said his behaviour became "consistently distressing and bizarre" over the course of the evening, with Kerr seen flailing his arms while laying on the floor.
He was assessed by a psychiatric nurse from outside the cell, who raised his risk rating to the highest level and mandated he be transferred to a specialist unit, but this did not occur.
About 6.30pm, he said "I'm dying" over his intercom, but there was no response, Ms Ellyard said.
A nurse visited his cell after blood was seen, but "wrongly concluded" it was from his burned hand, when the blood was actually from his head as he had been banging it, she said.
Kerr's movements began to slow from 7.40pm, with a prison officer noticing he stopped moving about 8.01pm and looking through the cell window.
He believed he saw Kerr's chest moving, indicating he was breathing, and tried rouse him using the intercom, before a code black emergency was called.
Kerr's cell door was not opened until tactical officers arrived at 8.18pm.
"That's a total of 17 minutes between Josh being visibly unresponsive and having his first access to medical treatment," Ms Ellyard said.
"He died in full view of custodial and health staff."
The inquest continues.
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Emily Woods - AAP