However, Deputy State Coroner John Lock What questioned how the prison nurses treated the aboriginal man after his release from the Princess Alexandra hospital two days earlier.

Garnett Mickelo was born in Cherbourg a small township in the South Burnett region, known for its sports people such as Willie Tonga and Eddie Gilbert.

In 1981 the then 17-year-old Mickelo was sentenced to life in prison for murder and served most of that sentence at Woodford Correctional Centre.

During his incarceration at the correctional centre he held positions such as tradesperson and tutor, he was also convicted multiple times for violence and threats against staff and damage to his cell.

A forensic pathologist that examined Garnett Mickelo's body after his death, said his heart was one of the worst he had seen in his extensive experience.

His heart was enlarged, had extensive damage from previous heart attacks, hardened arteries and large areas of dead heart muscle.

The pathologist also deemed the heart attack would have been caused by heart failure resulting in a heart attack, most likely a spontaneous event.

But, in the two days in the safety unit in the correctional centre, Garnett Mickelo's treatment came under question and while it could not be found to have caused his death, serious questions arose from his treatment.

It began right after he was sent to the correctional centre, after his visit to the hospital for heart treatment he was prescribed a new list of medicine to take for diabetes, nicotine addiction and his heart.

The correctional centre was not equipped with some of the drug he needed and as a result he missed out on some of his treatment and was given old medication.

To rectify this the hospital is now required to give any patient returning to a correctional centre a five-day supply of medicine, because of Garnett Mickelo's death.

The next potential fault in his treatment related to the nurses monitoring him, clearing him to go back to his regular cell, despite the fact he had just had heart surgery and could not walk.

The custodial manager was not satisfied with the nurses response to Garnett Mickelo's treatment and requested he stay in the safety unit.

He was also not listed for medical observations, despite his condition.

On his second night back from the hospital, Garnett Mickelo complained of chest heaviness after a walk, Nurse Maria Maynard, who is now deceased and will be the subject of another inquest, took medical observations but notes that he had 'no cardiac issues'.

On his last day in the correctional centre, there were no nursing records made of Garnett Mickelo until 7.30pm, but he did call a friend who said he was full of praise for his treatment.

No medical observations were made until he died.

At a shift change Safety Unit officer Mark Beswick took over at 10pm and started checking on prisoners at 10.10pm.

He became concerned for Mickelo when he could not see the inmate's chest moving, but may have seen movement on his hand.

Officer Beswick called his supervisor and a nurse at 10.15pm and a Code Blue was called three minutes later.

By the time they entered the cell with adequate security, it was 10.23pm and the nurse pronounced Garnett Mickelo dead two minutes later.

The nurse said at the time he reached Garnett Mickelo's body, he was cold and stiff.

The forensic pathologist said that claim was 'inconsistent' as it takes an hour for rigor mortis to set in and he was recorded as moving 10 minutes earlier.

A review into how emergent cases are treated found that a Code Blue should have been called immediately on suspicion of a medical emergency.

Coroner Lock deemed that many of the minor faults in Garnett Mickelo's treatment may have contributed to the circumstances that caused his death.