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A mentally ill New Zealander twice pressed the alarm button in his NSW jail cell saying "I've slashed up" but was not checked on until more than 11 hours later when he was found to have bled to death, an inquest has been told.
The inquest will examine whether the delay was because prison officers were watching a rugby league final between the Sydney Roosters and Melbourne on TV that night, said counsel assisting the coroner Simeon Beckett on Monday (local time).
Mr Beckett was giving an opening address at Glebe Coroners Court at the inquest into the death of Junior Fenika, who was found dead in his cell at Goulburn High-Risk Management Correctional Centre (HRMCC) on the morning of September 12, 2015.
He was born in New Zealand and came from a large Samoan family which moved to Sydney in 1996, although he never took out Australian citizenship.
From 2007 he spent considerable time in juvenile detention for violence and property offences, being transferred into an adult prison when he was 18.
Prison records revealed a "history of violent episodes".
In March 2015, he was moved for a second time to the HRMCC with a history of self-harm, mental illness and violence issues.
"It was clear that Junior Fenika developed mental illness while in prison and that his mental illness worsened over time," Mr Beckett said.
He was placed on medication by psychiatrists who were told he could heard voices telling him to hurt others, was paranoid, threatened self-harm, and appeared to develop a psychosis, but had a history of not taking his medication.
His latest sentence expired on August 11 2015, but he remained at HRMCC as the Immigration Department had cancelled his visa and was deporting him.
On September 9, the 23-year-old was captured by CCTV camera in his yard writing, possibly with toothpaste or soap, "God forgive me" and "Love Us All".
The last time he is seen alive was at 2.17 pm on September 11 when he is pacing in his cell.
"At 8.50 pm CCTV footage shows a dark substance emerges from the bottom of Fenika's rear cell door into his yard," Mr Beckett said.
"Crime scene photographs confirm this was Junior Fenika's blood".
At 9.17 pm he presses the alarm, saying "I've slashed up", repeating the call at 9.23pm.
The control room officer tells two roving officers about the call apparently saying Fenika "has asked for his stuff".
Neither officer approaches the cell, despite the Corrective Services policy stating that officers "are to respond to every call".
CCTV footage then shows a mix of water and blood being washed out of the cell into the yard.
"It is open to infer that by doing so Junior Fenika was attempting to signal to anyone watching on the CCTV...that he was in distress and in need of help," Mr Beckett said.
The coroner will also consider why the first two officers did not inspect the cell, why others who walked through and over the water failed to check it and the adequacy of his psychiatric treatment.
The inquest continues.
Where to find help:
Healthline 0800 611 116
Lifeline Aotearoa 0800 543 354
Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO)
Samaritans 0800 726 666
Alcohol Drug Helpline 0800 787 797
General mental health inquiries: 0800 44 33 66
The Depression Helpline 0800 111 757