The death of an Aboriginal teenager in a West Australian prison could have been prevented if he had received adequate medical care, a coronial inquest found on Tuesday.
Mr Yeeda, a 19-year-old Miriuwung and Gajerrong man, died from complications of rheumatic heart disease at the West Kimberley Regional Prison on May 3, 2018.
He was six weeks away from being released from prison.
Mr Yeeda had been due to see a cardiologist but the referral from the prison medical officer was not progressed to booking him an appointment.
The coronial inquest found had Mr Yeeda undergone surgery for the aortic valve replacement he needed, he could have survived.
Mr Yeeda. (Photo provided by his family.)
The inquest found the WA Department of Justice, WA Country Health Service, and WA Cardiology missed opportunities to treat Mr Yeeda.
Mr Yeeda's mother, Marlene Carlton, said her son was looking forward to life outside prison
"He wanted to do his time so he could come out and live with his dad on a station and work with horses," she said.
"There was a lack of communication between the prison and me â€" if anything happened to him, they should've called me, but they didn't.
"There should be a better system to monitor (the inmates) health, and they need people in the prison who understand Indigenous culture and health."
Advocates representing Mr Yeeda's family welcomed recommendations to improve information sharing and tracking of inmate healthcare, but said they did not go far enough to improve healthcare for Aboriginal people in prison.
National Justice Project principal solicitor and director George Newhouse said more needed to be done to ensure culturally safe healthcare.
"The coroner has failed to address the systemic racism in WA's justice and healthcare systems which led to Mr Yeeda's death," he said.
"Unless culturally appropriate healthcare delivered by Aboriginal medical services is provided to prisoners, we will see more needless deaths like that of Mr Yeeda.
"Governments must implement the recommendations of the Royal Commission into First Nations Deaths in Custody, which identified more than 30 years ago the low levels of cultural awareness among prison medical staff, particularly in relation to heart disease."
Congress of Aboriginal and Torres Strait Islander Nurses and Midwives board member and Wiradjuri woman Juanita Sherwood said prison staff should have followed rheumatic heart disease guidelines.
"Prison and health staff should have known better because we all know it's a big issue for Aboriginal and Torres Strait Islander communities that needs to be managed well," she said.
"The lack of treatment and follow-through reveal a negligent treatment of Mr Yeeda."
A Department of Justice spokesperson said the department acknowledged the findings of the coroner.
"All deaths in custody are taken seriously and systems and processes will be reviewed in light of the Coroner's recommendations," they said.