Corrections officers checked on Steven Freeman the morning of May 27, 2016 before moving on to the next cell, though there is evidence that suggests he may have already died, an inquest has heard.
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The coronial on Wednesday centred around supervision of the Indigenous man at and after his admission to the prison's methadone program, with the court hearing testimony from a corrections officer, the jail boss, and the manager of Justice Health.
The 25-year-old, who had been in prison since May 2015, was discovered dead in his cell at the Alexander Maconochie Centre by another prisoner about 11am on May 27, 2016.
Mr Freeman had started on the methadone program two days earlier, though the court had heard he may have misled the prescribing doctor about his dependence on opioids. An autopsy found the cause of his death was aspiration pneumonia due to methadone toxicity.
Medical experts have said while time of death cannot be pinpointed, the circumstances, including that Mr Freeman was cold when he was found at 11am, might place his time of death earlier that morning.
A corrections officer gave evidence at the inquest on Wednesday, telling the ACT Coroners Court he had seen Mr Freeman's foot twitch that morning when he opened the cell door and looked inside.
The officer, who hasn't been named to protect his identity, described Mr Freeman as laying on his back in bed with his hands crossed behind his head. The inquest had earlier heard Mr Freeman was in the same position when he was found dead.
The corrections officer told the court he was certain he had seen the toes on the man's left foot, which was not covered by a blanket, move before he continued onto the next cell.
The jail's muster policies have changed since Mr Freeman's death.
The inquest has heard evidence that the first week on a methadone program is the most dangerous, and changes have also since been made to the way in which prisoners receive their doses.
Bruno Aloisi, the acting executive director of Justice Health, told the inquest that the starting dose of methadone for a detainee beginning the program had been reduced from 30mg to 20mg.
He said this was "precautionary", as both were within guidelines.
Doses must be given before 2pm, so that nurses, who work until about 8.30pm, are available in the time of methadone's peak effects - which the inquest has heard is between two and four hours after dose.
Detainees and corrections officers could then report to the medical staff any potential adverse reactions in the prisoner patient, Mr Aloisi said.
There is evidence before the court that suggests Mr Freeman was "stoned" or "smashed" after his second dose, though there is also contrasting evidence that suggests he was quite lucid.
Mr Aloisi said once prescribed methadone, there was now a one day delay before a prisoner was administered their first dose, giving medical staff more time to consider the assessment and gather information.
This could include looking for potential symptoms of withdrawal from opiates, or behaviour that might be inconsistent with withdrawal.
Mr Aloisi said from day one to day six on, medical staff completed a pre-dose assessment for signs of intoxication. Two staff must now assess suitability for dosing.
Under questioning from counsel assisting the coroner, James Lawton, Mr Aloisi explained this process had been formalised since Mr Freeman's death, and there was now a document that listed symptoms of methadone intoxication, such as slurred speech or dilated pupils.
The hearing continues before Coroner Robert Cook.
