As a week-long inquest into the death in custody of Kamilaroi, Gumbaynggirr and Wakka Wakka man, Tane Chatfield, concluded, his parents called for an urgent overhaul of processes within the justice system.
Speaking outside the New South Wales Coroner's Court in Sydney on Friday, Colin and Nioka Chatfield demanded a number of changes.
"We want independent investigations into all black deaths in custody and [for] the law to be changed to close the monster's loophole where they investigate their own," Mr Chatfield said.
"We need more Aboriginal jobs and workers in the prison system. We want proper medical detox and rehabilitation programs within the system. We want all inmates to receive a free phone call when there is a medical situation."
Tane Chatfield was 22-years-old when he died in custody in Tamworth, a NSW regional city around 400 kilometres north-west of Sydney, in September 2017.
Throughout last week, the coronial inquest heard a timeline of events that led up to his death, which included testimony from his friend and ex-cellmate, Darren Brian Cutmore.
Mr Cutmore, who considered himself an "older brother" to Mr Chatfield, told the inquest that after attending court in nearby Armidale, Mr Chatfield was "happy as can be", and confident of being acquitted of the charges against him.
But when Mr Chatfield realised the pair would be placed in separate cells he became distressed, said Mr Cutmore.
That night, Mr Chatfield suffered multiple seizures and was taken to Tamworth Base Hospital at about 11pm.
One correctional officer who guarded Mr Chatfield overnight told the coronial inquest that he recalled Mr Chatfield requesting and receiving Panadol and Endone on three separate occasions.
Tane Chatfields parents Colin and Nioka Chatfield speak to supporters gathered outside the inquest into Tane Chatfields death. Source: AAP
Another correctional officer, Harrison Fittler, told the inquest that Mr Chatfield had "curled himself into a ball" and complained of body aches sometime between 1:30am and 2am on September 20.
"He mentioned body aches and pains and described them as a '10 out of 10 pain,'" said Mr Fittler.
Mr Fittler said Mr Chatfield was unhappy about being discharged from hospital after daybreak due to lingering pain, but appeared "calm and relaxed" upon his return to the prison.
"From what I could see he wasn't disoriented or showing any signs of concern," he said.
When Mr Chatfield was returned to the prison, he was told he was to stay in the one-man cell he had been placed in to wait for hospital discharge paperwork, while his fellow inmates were allowed out of their cells.
Janeen Adams, a nurse unit manager who attended to Mr Chatfield after his return to the prison from hospital, told the inquest she was not aware that Mr Chatfield had suffered multiple seizures the previous night, when she directed him to rest alone.
Ms Adams said Mr Chatifield appeared "alert and calm", provided "appropriate" answers to questions, and told her he was feeling okay.
Prison security manager Stephen McPherson told the inquiry he recalled Mr Chatfield being upset with having to stay in his cell.
"He tried on multiple occasions to change my mind," said Mr McPherson. "When I opened the door, he had a towel and a bag containing toiletries.
"The only words I remember him saying were 'I want to shower'. He was probably shouting."
'We have been stuck'
Less than an hour later, fellow inmate Brendon O'Leary alerted officers after seeing Mr Chatfield hanging in his cell.
"I opened the door and there was a quick conversation," correctional officer Russell Smith said.
"But all I heard in the conversation were two words: Chatfield and hanging."
Mr Smith and three other guards rushed to Mr Chatfield's cell, lowered him to the floor and commenced CPR.
"Neither of us could find a pulse," Mr Smith said.
Footage presented at the inquest showed Mr Chatfield's body being lifted out of a cell and carried into a corridor within the cell-block shortly after paramedics had arrived.
Mr Chatfield was taken to an intensive care unit at Tamworth hospital and died two days later.
NSW Corrective Services at the time said Mr Chatfield's death was not suspicious, telling his family he took his own life.
Nioka Chatfield said her life was changed forever upon finding her son hooked up to a life-support machine.
"Waiting almost three years with no answers about our son's death has taken a huge toll on our family," she said.
"With grieving you are supposed to have a process of acceptance and moving forward. But without answers we have been stuck."
Ms Chatfield told the inquest she hoped to return home to Tane's six-year-old son with her head held high.
Supporters of Tane Chatfields parents Colin and Nioka Chatfield pose with them for a photograph outside the inquest into Tane Chatfields death. Source: AAP
"He only had one son - the little boy I'll give these folders to... so he can know I did the best of my ability to fight for his father," she said.
"I have to stop intergenerational trauma in my family this week. And let me be the last Australian mother crying for an Aboriginal boy who died in custody."
Tane Chatfield's older brother, Alister, had pre-recorded a video, which was presented at the inquest. He said Tane was "like a shadow" to him, because the two had been so close.
"I wish I could turn back time to when I last saw him and tell him I loved him again," he said.
The inquest was headed by deputy state coroner Harriet Grahame, who will now find cause of death and may also make recommendations to help prevent similar deaths in the future.
Aboriginal rights advocate, Padriac Gibson, who supported the Chatfield family during the inquiry, said the coronial inquest process was not set up to deliver justice.
"It's not about prosecuting someone, finding someone criminally accountable and holding them accountable, that's not what an inquest is about," he said.
"An inquest in many ways masks the fact that there is violent state actors who are responsible for the death of Aboriginal people and shifts it into a more procedural question about if procedures were better followed [could the death in custody have been prevented]."
