Death in custody inquest finds evidence of complacency and incompetence

Dictor Dongrin, pictured in 2018, died in prison in 2022. (Supplied: Rebecca Deng)

Dictor Dongrin was suffering from alcohol withdrawal when he died in the medical unit at Clarence Correctional Centre.

NSW deputy coroner Rebecca Hosking found the conduct of prison medical staff should be reviewed by professional bodies.

A NSW coroner has recommended medical staff who failed to treat, transfer or monitor a newly arrested prisoner for alcohol withdrawal should have their conduct reviewed by professional councils.

Dictor Dongrin and his brother were arrested in June 2022 after a violent and drunken incident at the family home in Coffs Harbour, in which their father Moses Dongrin was allegedly assaulted.

A coronial inquest heard the 29-year-old entered the Clarence Correctional Centre the day after his arrest, and by 2:29pm the following afternoon he was dead in a prison medical unit cell.

Dictor Dongrin, who later died in Clarence Correctional Centre, was described by his parents as a loving young man. (Supplied: Facebook)

The court heard no physical medical observations were made during the previous 21 hours.

Deputy State Coroner Rebecca Hosking found Mr Dongrin died "from cardiac arhythmia in a state of alcohol withdrawal … and that timely and adequate medical intervention could have prevented death".

"Despite a score of eight [on a drug and alcohol scale] there was no appropriate consideration made to transfer Mr Dongrin to hospital."

Judge Hosking said the absence of any clinical observations following the initial intake assessment until the time of Mr Dongrin's death made his treatment "wholly inadequate" and it was likely he had been dead for up to 2 hours before resuscitation was attempted.

"Timely and adequate management could have prevented his death," she said.

Judge Hosking recommended the conduct of two nurses working at the jail be reviewed by the Nursing and Midwifery Council, and the actions of the specialist doctor overseeing drug and alcohol treatment at the facility be referred to the Medical Council of NSW for review.

Ian Fraser told the court Dictor Dongrin's death was entirely preventable. (ABC Coffs Coast: Claire Simmonds)

Barrister Ian Fraser, who represented Mr Dongrin's family, told the inquest: "The cruel irony is Dictor Dongrin died in a clinical observation cell where no clinical observations were taken."

Mr Fraser attributed the failures to prison medical staff "working in a system of apathy which created a lack of responsibility".

The Clarence Correctional Centre is Australia's largest prison, housing up to 1,70