Zachary James David Holstein was rushed to Caboolture hospital after he was found unconscious in his cell at the Sunshine Coast centre on February 8, 2016.

According to a coronial inquest delivered last week, the 23-year-old “intelligent, honest” man died surrounded by his family on February 12.

The inquest found Mr Holstein had a history of substance abuse, which was exacerbated by the death of his partner in 2013.

Mr Holstein was convicted of several drug- and fraud-related offences and ended up in prison in 2015 after he contravened his parole conditions twice for a grievous bodily harm charge the year before.

During a police investigation of Mr Holstein's death, fellow inmates said they got along with the young man and were surprised he had taken his own life.

When Mr Holstein first entered custody he was placed under medical observation after suffering severe drug withdrawal. He reported using ice, heroin and Xanax, according to court documents.

On October 1, 2015, he was assessed as being at high risk of self-harm and suicide and was placed on 15-minute observations.

These observations were eventually discontinued on October 23 when a psychologist report noted he denied any current feelings of self-harm.

Deputy state coroner John Lock said it was “of some concern” he was first seen by a visiting medical officer on November 5, after he put in a number of medical request forms to nursing staff, stating he was suffering from depression but no longer had thoughts of suicide or self-harm.

According to court documents, the doctor said the “prolonged delay” was likely due to increasing prison population and hence a growing patient list, high workload, long lists and not enough resources.

In delivering his findings, Mr Lock recommended Metro North HHS “urgently consider additional resourcing” of offender health services at Woodford to make sure prisoners can see a doctor within at least seven days or a timeframe similar to those experienced by members of the general public in the community.