This report contains the first name of an Indigenous person who has died.
A First Nations woman reported suicidal thoughts and complained multiple times that she was not receiving her usual mental health medications in the weeks before her death, a coronial inquest in Sydney has heard.
The ABC reports the inquest heard on Monday that the 29-year-old woman, known as Monique, was sent to Westmead Hospital after a suicide attempt but did not receive a referral to the mental health team.
11 days later, she took her own life.
Monique was a mother of five and a much-loved sister and daughter, the Lidcombe Coroners Court heard.
Her mother and aunt attended the first day of the inquest wearing shirts bearing an image of her face and her artwork.
The ABC reports deputy coroner Joan Baptie will examine whether Monique received the same standard of healthcare available in the community, whether her suicide risk and the service of an apprehended violence order was managed appropriately, and the suitability of the cell conditions where she died.
Counsel assisting Ragni Mathur SC described Monique's life as one filled with challenges of intergenerational trauma, childhood sexual abuse and domestic violence, the ABC reports. On Monday the court heard that when Monique entered custody on December 12, 2024, she was taking medications for sleep, chronic pain, anxiety and depression.
Within days, she was reporting suicidal thoughts, saying she was not coping in prison and describing voices telling her to harm herself or others.
The court also heard she made repeated requests to access her usual mental health medication, and her community health records were requested but not delivered, the ABC reports.
Ms Mather said Monique was never seen by a consultant psychiatrist or the suicide outreach team during her three weeks in custody.
The ABC reports the inquest also heard evidence of staffing pressures within the prison, including an officer's journal entry describing a wing in "total chaos" with "too many mental health inmates", no psychologist assigned to the unit and correctional officers being expected to perform psychological duties. The court also heard only one member of the suicide outreach team was rostered throughout the Christmas and New Year period.
The court heard Monique requested a cellmate and it was recommended she be placed in group cell accommodation, but this was never implemented because she was put in segregation after an attempted escape at hospital, the ABC reports.
Monique died alone in her cell two days before an order to end her segregation was due to take effect.
During the first day of the inquest, Counsel assisting questioned why someone with Monique's mental health history was housed in a cell with ligature points and an outdoor area without CCTV and which was difficult for officers to observe.
The inquest will return to Lidcombe Coroners Court on Tuesday.
More than 630 Indigenous people have died in custody since the Royal Commission into Aboriginal Deaths in Custody brought down its findings and issued over 300 recommendations in 1991.
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