The family of a mentally ill indigenous man who died in Sydney's Long Bay jail have reacted angrily after a coroner found five prison officers were not motivated by malicious intent.
Family and supporters of David Dungay shouted "no justice" outside court after NSW deputy coroner Derek Lee on Friday handed down his finding into the 26-year-old's death in custody in December 2015.
Mr Lee rejected a submission from Mr Dungay's family that four Corrective Services NSW officers be referred for disciplinary proceedings.
The coroner said the officers who moved Mr Dungay - a diabetic who suffered from chronic schizophrenia - from one cell to another because he refused to stop eating biscuits were let down by systemic deficiencies in their training.
"It has ... been noted that the available evidence does not rise so high as to suggest that the actions of the CSNSW officers in moving David between cells ... were motivated by malicious intent," Mr Lee said.
"But rather (it was) a product of their misunderstanding of information that was conveyed at the time."
Mr Dungay died of cardiac arrhythmia at Long Bay Hospital after being restrained in his cell.
Footage played during the inquest showed Mr Dungay repeatedly screaming "I can't breathe" to which one officer replied: "You're talking, you can breathe."
He was restrained by five officers and pinned down on the bed and was seen spitting blood as he was being transferred to another cell.
After being placed in a second cell, he was injected with the sedative midazolam.
Mr Lee described attempts to resuscitate Mr Dungay as "low clinical standard and lacking in several vital areas".
During the inquest, counsel assisting Mr Dungay's family accused one officer of "embarking on a power play" and described his behaviour as "repugnant and reprehensible".
Mr Dungay's family angrily confronted Corrective Services NSW commissioner Peter Severin outside court on Friday. They stood in front of his car as he tried to leave.
Mr Dungay's nephew, Paul Silva, said the guards should be charged.
"The First Nation people get treated inappropriately in everyday living," Mr Silva said outside Lidcombe Coroners Court.
"We're calling on the DPP to look into this because there's enough evidence there for criminal charges.
"Don't let this Aboriginal death go under the carpet because I guarantee there's going to be more where that came from."
The coroner - who made 20 recommendations - said evidence given during the inquest by Charles Xu, the nurse who injected Mr Dungay with the sedative, should be forwarded to the Nursing and Midwifery Board of Australia and his registration be reviewed.
Mr Lee was critical of Mr Xu's decision not to stay in the cell and medically assess Mr Dungay after hearing him complain he couldn't breathe.
Mr Xu was ordered out of the cell by prison officers and the counsel assisting him argued during the inquest he was confronted with a complex situation and didn't represent a danger to the public.
Mr Lee also recommended changes to Corrective Services and the Justice Health and Forensic Mental Health Network.
"We recognise that this has deeply affected the family and that the pain they have experienced from his passing will continue well into the future," Mr Severin said.
"I also acknowledge the organisational failures at that time and note that we have made many changes to policy and training procedures as a direct result of Mr Dungay's death."
Australian Associated Press