A New South Wales coroner’s inquest has revealed evidence of complacency and incompetence in the medical care provided to a prisoner who died shortly after being admitted to Australia’s largest prison. The inquest focused on the circumstances surrounding the inmate’s death within 24 hours of entering the correctional facility. The coroner’s findings point to systemic issues in the assessment and treatment of prisoners’ health needs. Recommendations have been made for comprehensive reviews of the conduct of medical staff involved in the case. The coroner seeks to prevent similar deaths in the future by addressing deficiencies in healthcare protocols within the prison system. The report does not detail the cause of death, only highlighting failures in due diligence and care. Authorities are expected to respond to the recommendations in due course.