Warning: this story contains the name and image of a person who has died, and disturbing details.

The inquest into the death in custody of a 32-year-old Indigenous man has heard correctional officers refused to open the door of this cell, even as he lay unconscious.

The hearing on Monday also heard a tactical operations group (TOG) officer believed Yorta Yorta and Gunaikurnai Joshua Kerr was "putting it on" and was "coherent" when he writhed in pain in the lead-up to his death.

Mr Kerr died whilst on remand on August 10, 2022, at the privately run Port Phillip Prison. In the hours before he died, he had lit a fire in his cell and severely burnt his hand, resulting in a transfer to St Vincent's hospital for treatment, alongside TOG officers. Before he was formally discharged, Mr Kerr was taken back to Port Phillip.

Mr Kerr - who had previously disclosed he had taken methamphetamine - was placed in a cell with the on-site medical unit which could be viewed in real-time via CCTV. Tog instructed the cell to remain closed unless their own staff were present.

On Monday, associate nurse unit manager at Port Phillip Prison, Brooke Metcalfe, told the inquiry when she returned to her office at 7.30pm, she saw Kerr had become unresponsive. Getting to his cell door, she recalled seeing him lying on his side against the wall. Believing he was unconscious, Ms Metcalfe and some colleagues requested to enter the cell.

"I said 'the door needs to be opened now'," she told the court.

Ms Metcalfe said she was told by correctional officers they were waiting for TOG. Asked if the correctional officers refused to open the door, Ms Metcalfe responded: "yes."

The court had previously heard Mr Kerr was "visibly unresponsive" for 17 minutes before receiving medical treatment, having called out "I'm dying" with no action from prison staff. His behaviour was described by counsel assisting the coroner, Rachel Ellyard, as "distressing and bizarre."

Ms Metcalfe agreed Mr Kerr's response was to a drug overdose reaction, which medical staff had misdiagnosed. She also agreed his response in the cell was due to the side effects of methamphetamine use, rather than psychosis or behavioural.

"I think Josh didn't get the treatment he needed in hospital…I don't think we got the information we needed on his return," Ms Metcalfe said.

"I also believe that being a health professional is extremely hard. Because it is such a wide range of diagnoses... as a nurse, we don't diagnose."

Asked if there was anything she could have done differently in identifying and helping Mr Kerr's needs, Ms Metcalfe told the inquiry: "...on reflection... I probably should have escalated up to supervisor or higher... we get that door open."

TOG officer Luke Clarke, who's body-worn camera revealed him saying Mr Kerr was "completely coherent" and there was no reason to open the cell, earlier told the inquiry he agreed with the summation it was a "very high bar" for a cell door to be opened without the prisoner inside being restrained or unconscious first.

"If you were to be incoherent, incapacitated, then definitely we would open that cell door immediately," Mr Clarke said when asked what could lead to a cell being opened.

Asked by Ms Ellyard if the opening of a cell "only happens if the prisoner is visibly unconscious," he said this was commonplace.

"In my experience that is the case, yes," he said.

He also disagreed with Ms Ellyard's summation that Mr Kerr had called out for help. When told body worn camera footage recorded Josh saying, "I need some help, please," Mr Clarke told the inquiry: "I've listened to the footage, and I did not hear that."

The inquest before coroner David Ryan continues.

13YARN 13 92 76

Aboriginal Counselling Services 0410 539 905