A 36-year-old Anaiwan Dunhutti man, Nathan Reynolds, died in 2018 gasping for air on a prison floor from an asthma attack after guards took an “unreasonably” long time to come to his aid. The NSW deputy coroner Elizabeth Ryan said the “confused, uncoordinated and unreasonably delayed” response by prison guards and health staff deprived Reynolds of “at least some chance” of survival. Reynolds’ family, who have waited almost three years for answers as to how and why he died – and, crucially, for somebody to be held responsible – heard the NSW deputy coroner give a brief summary of her findings on Thursday.