A prison guard lied to Indigenous woman Veronica Nelson about calling a nurse to help her in the hours before she died.
Veronica screamed in pain and complained of cramps in her legs and fingers before she was found dead in her cell at Melbourne's Dame Phyllis Frost Centre in January 2020.
She had been arrested three days earlier on suspicion of shoplifting and was denied bail.
Veronica had made more than a dozen calls to prison guards for help on the night she died, an inquest into her death has been told.
Prison guard Tracey Brown was on the receiving end of those calls, and at an inquest on Friday admitted she had lied to Veronica five times when she desperately called for assistance.
"I was doing my duty but could I have done better," Ms Brown testified.
As Veronica made increasingly distressed calls through the prison intercom, Ms Brown told her that she had alerted medical staff, but did not actually do so until almost an hour later.
When she did speak to prison nurse Atheana George she told her Veronica had gone to sleep, when she had no idea whether that was the case.
Ms Brown agreed it was inexcusable that she had not walked a further 10 metres to Veronica's cell during her hourly patrols, to check whether she was breathing.
Ms Brown agreed under cross-examination that she had failed in her duty of care and had made medical decisions about Veronica's care that she was not qualified to make.
Veronica was "utterly reliant" on Ms Brown, trusted her, and was trying to follow her suggestions to take salt and have a shower to relieve her cramps, the court heard.
Veronica was found dead on the floor of her flooded cell about 7.30am on January 2, with the shower still running.
Ms Brown rejected suggestions that she saw Veronica as just another drug addict crook, but acknowledged that she did not think there was anything particularly unusual about Veronica's case.
"I've seen it before and I'll see it again," she testified.
Ms Brown said that while she was aware there had been a Royal Commission into Aboriginal Deaths in Custody, prison management had never told her there were particular risks facing Aboriginal people in prison.
The court also examined minutes of a meeting by prison management, in which Tracey Brown was commended for how she dealt with Veronica's intercom calls, and a prison manager said she was proud of how Veronica had been treated in the final hours of her life.
The Yorta Yorta woman died from undiagnosed Wilkie's syndrome, in a setting of heroin withdrawal.
More than 60 witnesses are expected to be called during a month-long inquest, examining the adequacy of prison healthcare, the impact of Veronica's Aboriginality and Victorian bail laws.
The inquest continues on Monday.
Australian Associated Press
