Staff at Port Phillip Prison in Victoria watched an Indigenous prisoner die in his cell instead of helping him, a coroner has declared in findings announced today.

Coroner David Ryan said there were numerous failures in the lead-up to the death of 32-year-old Josh Kerr on August 10, 2022, including flawed protocols at the jail.

The report stated Mr Kerr had taken drugs and alerted staff on a cell intercom, telling them: “I’m dying.”

The court was told prison staff watched Mr Kerr become agitated and erratic via a security camera and through a cell trap door, but did nothing because a directive stated the cell door could only be opened by Tactical Operations Group officers.

Mr Ryan collapsed at 7.43pm and ‘code black’ was not called until 8.10pm, but TOG officers took another eight minutes to arrive and open the cell door.

Mr Kerr was pronounced dead at 8.41pm.

Tune coroner said there was a “disproportionate focus on security concerns”.

“TOG directions should not prevent a prisoner from receiving medical treatment,” he said.