Warning: this story contains the name and image of a person who has died, and disturbing details.
An Indigenous man removed the skin from his hand without showing any pain in the hours before his death but was not deemed by medical staff to be under the influence of drugs.
Yorta Yorta and Gunnaikurnai man Joshua Kerr, 33, died whilst on remand on August 10, 2022, at the privately run Port Phillip prison.
In the hours before his death, Mr Kerr lit a fire in his prison cell and was transferred to St Vincent's hospital for treatment of burns on his hands and arms, alongside tactical operations group (Tog).
Tog officers transported Mr Kerr back to Port Phillip prison before he had been formally discharged and whilst he was awaiting the re-dressing of his wounds. He was found dead in his isolation cell three hours later "in full view of custodial and health staff" on CCTV.
The inquest heard on Tuesday that clinical nurse coordinator at the prison, Rhiannon Velden, was unsure if Mr Kerr had ingested drugs, despite telling her directly he had taken methamphetamine. She said whilst he was "very talkative," you "can't take as gospel" what patients say.
Ms Velden and her colleague, nurse Manuel Arrietta, witnessed Mr Kerr "deglove" the skin off his hand in the aftermath of the fire, with Ms Velden saying he did so with "no flinching".
Ms Velden told the inquest that while it surprised her, she didn't assume it was due to drug use.
Mr Arrietta told the inquest she witnessed Mr Kerr remove the skin from his own hand when the ambulance was called, arguing "no person in his right mind" would be able to perform the act painlessly.
"To me, it's odd…something [is] wrong]," Mr Arrietta said.
However, he told the court he believed at the time the behaviour could have been "psychiatric" rather than drug induced.
Ms Velden said Mr Kerr's blood pressure and pulse were "slightly higher" but told the inquest she "didn't believe so" when asked if this was due to methamphetamine use, attributing it instead to the stressful situation in the aftermath of the fire in the cell.
Ms Velden said she had not received formal training on the acute effects of methamphetamine use. She performed a Glasgow Coma Scale (GCS) test on Mr Kerr, but did not follow the acute poisoning management guideline, arguing in her experience it wasn't as effective as a GCS.
Under questioning, Ms Velden said she wouldn't apply the acute poisoning management guidelines unless she was 100 per cent sure of what a patient had ingested, as she understood this was the procedure.
"I wasn't going to give him sedatives as I wasn't 100 per cent sure of what he had taken," she said.
Coroner David Ryan previously heard Mr Kerr had 8.1 milligrams per litre of methamphetamine in his system which counsel assisting the coroner, Rachel Ellyard, said was "a very, very high level".
Mr Arrietta said he didn't believe Mr Kerr was affected by drugs and noted Mr Kerr had never told him directly he had ingested anything.
"In my experience they [prisoners] usually tell us what they took," he said.
Mr Arrietta agreed he would only use the acute poisoning guidelines if he was sure a substance had been used, saying he would only conduct an assessment on the symptoms based on the guidelines if he was aware what drug was taken.
The job of four people
The Inquest also heard from Indigenous man Roy McPherson who was working as the senior Aboriginal cultural advisor at Port Phillip prison at the time of Mr Kerr's death.
He described Mr Kerr as very sensitive and guarded about new people, albeit knowing him at "arm's length only."
"He seemed to have a code of ethics in some way that were different to other prisoners," he said.
Witnessing Mr Kerr remove the skin off his hand, Mr McPherson told the inquest: "He couldn't have felt anything…it was horrific to watch."
"He didn't appear to feel pain."
Mr McPherson also painted a picture of difficulties attending to the cultural welfare of all Indigenous prisoners due to staff shortages, which involved him running between wards to see an average of 38 men every day.
Asked if this lack of staff meant he had to make difficult decisions to prioritise Aboriginal prisoners, he stated: "Absolutely".
Mr McPherson described Aboriginal welfare at the privately-run facility as being cold, saying running group meetings and offering a self-published paper for inmates to read as being stopped by the prison.
"My role had absolutely no authority," he said.
He described reading racial slurs written on the toilet wall staff only areas and was once told to "pull down your mask and show us" when he said he was Aboriginal during a staff meeting.
The inquest continues.
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