Inquest into the death of Nathan REYNOLDS

36y · Male·bronchial asthma

Nathan Reynolds, a 36-year-old Aboriginal man with severe asthma, died from bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease management. On the night of his death, correctional officers took 11 minutes to reach him and a nurse took 22 minutes to arrive—delaying ambulance callout by 18 minutes. Expert evidence confirmed that earlier ambulance dispatch could have given him a chance of survival. More fundamentally, during his four months in custody, Nathan's severe asthma was never properly assessed or managed; he was never referred for Chronic Disease Screening, had no Asthma Action Plan, and was issued at least seven new Ventolin puffers—a major red flag for uncontrolled asthma that went unheeded. System failures included rigid procedures requiring three officers before medical assistance was called, absence of specialist respiratory input, and poor clinician understanding of chronic disease management protocols.