The sister of an inmate who took his own life in the ACT's prison said the system failed him in "the highest possible manner", while blasting an inquest for treating her brother with complete disregard.
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A coronial inquest has now finished hearing evidence into the suicide of the prisoner, 30, in July 2013.
The court spent four days scrutinising the circumstances surrounding his death, particularly a decision to move him from the closely controlled and supported environment of the Crisis Support Unit a day earlier.
The inmate's condition had been stabilising, and a decision was made to free up a bed in the overcrowded Crisis Support Unit by sending him to a nearby health ward.
That ward has been criticised for its isolation and poor design for at-risk prisoners, but the ongoing overcrowding crisis meant the only other suitable areas for the prisoner were full.
On the evening of his death, the inmate had a meal with his close friend and fellow detainee, before being sent back to the health ward to spend the night alone.
He killed himself soon after.
His sister, speaking outside court on Friday, said she was extremely disappointed and angry with the coronial process.
"The death of my brother whilst in custody has been a tragic event in my family's history," she said.
"More tragic has been the absolute disregard with which the coronial inquest has been handled."
"This coronial inquest has treated my brother and my family with complete disregard."
She said the family hoped the process would have brought dignity to the events of her brother's death.
But she said the experience had been the opposite.
"I am totally disappointed in the system and the people who have made it their job for the system to fail someone in the highest possible manner, and for the judicial system to condone their actions," she said.
The inquest is yet to deliver any findings, and will do so at a later date.
At the end of the evidence, Coroner Bernadette Boss acknowledged the family, who sat through the four-day hearing.
"I hope that these proceedings have been of some comfort to you for your loss," Dr Boss said.
The inquest has looked at issues of overcrowding, and flawed information sharing between mental health workers and ACT Corrective Services.
Psychiatrist Andrea Rapmund, who assessed the inmate on the day of his death, did not know the design of the health ward her patient was being sent to.
The inmate had told her he was "a bit down" and had been thinking of his own death, but stated he did not want to kill himself any time soon.
The inquest heard evidence that, had she known of his accommodation, the psychiatrist may have at least expressed concern or had a conversation with those responsible for the move.
Leading forensic psychologist James Ogloff said the ward was inappropriate for a mentally ill prisoner still showing symptoms.
The ensuite where the prisoner took his own life had a dangerous bathroom fixture and could not be seen by guards standing outside.
Professor Ogloff said a visit to the scene of the suicide on Thursday "cemented my view" of its inappropriateness.
Senior Alexander Maconochie Centre staff defended the move during the inquest.
Prison boss Don Taylor said that the inmate was not assessed as an immediate suicide risk, and that other areas of the jail presented similar dangers to the health ward.
Earlier on Friday, area manager Jennifer West denied the ward was isolated, saying occupants would have had 21 reasons for interaction with staff in a single day.
Counsel assisting Ken Archer questioned why David Eastman, described as a "difficult" inmate who impacted on other detainees, was kept in the health ward.
"What I'm putting to you is that people are put there either because there is no other place to put them, which may be relevant to the case of [the deceased inmate], or because it's isolated?" he asked.
Ms West replied:
"No, that's incorrect."
The inquest heard there were just five spare beds for male detainees inside the AMC in the period leading up to the suicide.
The inmate was classified as a "protection" detainee, meaning there were only two other units he could go to other than the Crisis Support Unit and the health ward. Both were full.
Before the death, the prison was already in the process of major reforms to its treatment of at-risk prisoners.
The suicide accelerated those processes, and significant change has now occurred, winning the praise of Professor Ogloff and others.
Dr Boss will deliver her findings at a later date.
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