Here at day four of the inquest into death of Nathan Reynolds. There was a brief adjournment. We are hearing now from CO Fifita. He was with CO Singh (who we heard from yesterday). #JusticeForNathanReynolds

Before the break, CO Fifita was asked by Counsel Assisting if there was anything he would have done differently on the day that Nathan passed. He said 'I wish I was not there, took a sickie.' #JusticeForNathanReynolds

Q (from Reynolds family's counsel): 'Is it correct to say that you formed a view that inmates were doing everything for Nathan that you could do for him?'
A: 'Yes, sir.'
Q: 'You couldn't see his face?'
A: 'No, sir.'
#JusticeForNathanReynolds

Q: 'He went stiff?'
A: 'He went stiff, yes.'
Q: 'The plan to get Nathan to the clinic involved him being lifted into the chair. It was when he was lifted that he seized.'
A: 'Yes, sir.'
#JusticeForNathanReynolds

Q: 'You had no way of knowing of [Nathan's friends inside] first aid knowledge? You had no way of knowing if moving him would deteriorate him?'
A: 'No, sir.'
Q: 'And it was the inmates who then moved him into the recovery position?'
A: 'Yes, sir.' #JusticeForNathanReynolds

Q: 'Were you relying on [Nathan's friends] to tell you if Nathan was still breathing?'
A: 'I was keeping an eye out if something needs to happen. There was lots happening.'
#JusticeForNathanReynolds

Q: 'You didn't check his airway?'
A: 'No, sir.'
Q: 'You didn't listen for his air?'
A: 'No, sir.'
Q: 'You didn't check his pulse?'
A: 'No, sir.' #JusticeForNathanReynolds

Q: 'Fair to say that your obligation, if he had no pulse, was to commence CPR?'
A: 'Yes, but I thought he was still with us.'
Q: 'But you didn't know he didn't have a pulse? What you saw was the movement of his chest and feet, from 3-4 feet away?'
A: 'Yes, sir.'

Q: 'You said you were focussed on Nathan, [his friends] and what was happening there. You were focussed on what was happening with the other inmates, and you were focussed on your safety, is that right?'
A: 'Yes, ma'am.'
#justicefornathanreynolds

Q: 'You decided you would take on [Nathan's friends] Preo & Robinson's assistance?'
A: 'Yes. I feel comfortable with Mr Preo. With the boys, it's better for them to help each other out. With their comradery [INAUDIBLE]. I feel comfortable that way.' #JusticeForNathanReynolds

CO Fifita now excused. CO Phali has just been called. CO Phali was the night senior on duty of the night of Nathan's death. #JusticeForNathanReynolds

Very important usual caveats: this is being written from the overspill room, where we are beholden to microphone issues. The transcripts are authoritative on this, will make any corrections brought to my attention and review as often as I can.

CO Phali now.
Q: 'If you were going to attend a wing, you'd need three officers at any time?'
A: 'Correct.'
Q: 'You might have, in a minimum security setting, inmates not in a cell.'
A: 'Correct.'
#JusticeForNathanReynolds

Q: 'Was there a rule that if there was a [call], that a nurse wouldn't be called until the inmate was sighted?'
A: 'Depends [on the concern].'
Q: 'Depending on?'
A: 'Chest pains, difficulty breathing, no answer.'
Q: 'What would you do then?'
A: 'Call a nurse, ambulance.'

Q: 'You were notified that Nathan had difficulty breathing & needed a nebuliser?'
A: 'Correct.'
[...]
Q: 'CO Fawzy's view was that you don't call a nurse until you sight the inmate-'
A: 'When he said he had difficulty breathing, I called for a nurse.' #JusticeForNathanReynolds

Q: 'There's no evidence that the COs were told that they needed to take Nathan to the clinic-'
A: 'I didn't tell them.'
Q: 'How did you know if they were going to take him to the clinic if you didn't ask them?'
A: 'They told me they were taking the wheelchair [for that].'

Q: 'Are you following up with them about if they're bringing him to the clinic?'
A: 'No.'
Q: 'Are you waiting for them to contact you about bringing him to the clinic?'
A: 'Yes.'
Q: 'Are you wondering what the status is?'
A: 'Not until I receive the radio call.'

Q: 'You tell CO Fawzy to head to H-Wing, take Nathan to the clinic, after the first call?'
A: 'Yes.'
Q: 'You then call someone to request a duty nurse-?'
A: 'Yes & ambulance.'
#JusticeForNathanReynolds

Q: 'Do you think, if you'd requested that, that you would tell the COs?'
A: 'No. They would know in the [radio] system. They don't have to be told.'
#JusticeForNathanReynolds

Q: Does it surprise you that it took eleven minutes between the call & COs walking over?
A: Yes.
Q: Does it concern you, that response time?
A: The systems didn't always match the clocks in the centre. If it took eleven minutes, that's very concerning.
#JusticeForNathanReynolds

Q: 'On the CCTV, Fawzy gets a wheelchair, within 30 seconds Nathan deteriorates rapidly. It appears that's occurred 18 minutes after the first call. Then, CO Singh says you need an ambulance, is that correct?'
A: 'Yes.'
#JusticeForNathanReynolds

Q: 'Do you agree that's a significant amount of time to have passed?'
A: 'Yes.'
Q: 'Were you not following up to find out where the nurse is, if you've requested that?'
A: 'Well, she was on her way from [another gaol].'
#JusticeForNathanReynolds

We are now adjourned for lunch. #JusticeForNathanReynolds

We are back now, hearing from a nurse (name wasn't heard in the spillover room). Currently discussing sources of Justice Health information: reception screening, what someone tells them, their own observations & electronic record systems. #JusticeForNathanReynolds

'Can I call him patient?'
Counsel assisting: 'Yes. Nathan is another way you can refer to him.'
'Okay, I usually just call them my patient.'
#JusticeForNathanReynolds

Q: 'You heard from Nathan that he was taking ventolin for his asthma. Did his use of a nebuliser say something to you about the degree of severity?'
A: 'I ask them how often they use it. It says to me, what I'm looking at, he's not exerted. So, I put him on the waitlist.'

Q: 'Does the nebuliser suggest that he relied on the puffer regularly?'
A: 'He said he would use it three times a day. That says to me that he should be on a preventer. That's why I put him on the doctor's list.'
#JusticeForNathanReynolds

Q: 'In 2017, Nathan became ill in prison. He reported two days of worsening wheeze. He was using 12 puffs of ventolin an hour.'
A: 'That's a lot.'
Q: 'Would that information have been relevant to you?'
A: 'At the time we look at the patient as they appear in front of us.'

Q: 'What does the 84 [on file] indicate?'
A: 'That indicates that the patient has been waiting 84 days.'
Q: 'It's got: triage category 2. Does that mean [address] within 28 days?'
A: 'Two weeks.'
Q: 'Does that 84 strike you as uncommonly long?
A: 'Yes.'
#justicefornathanreynolds

Q: If someone's wheezing, but can still walk and talk — is there consideration for how they'll manage risk, if there's one nurse overnight across three gaols?
A: The medical team would decide if this place is safe or not.
Q: What do they take into account?
A: [His history.]

We've just heard that there were no reviews of Nathan's chronic health by a specialist Aboriginal clinic from the 119 days between when he was put on the waitlist and his death. #JusticeForNathanReynolds

Q: 'That amount of time, 119 days, was the number of days he sits on the list until he's seen?'
A: 'Yes.'
#JusticeForNathanReynolds