Coroner says death at Port Phillip prison was preventable and the result of a series of missed opportunities
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For 16 minutes, an Indigenous man was left unconscious in his prison cell before dying in what his mother describes as a system lacking care and compassion for human life.
A series of missed opportunities culminated in the preventable death of 32-year-old Yorta Yorta and Gunaikurnai man Joshua Kerr in August 2022, Victorian coroner David Ryan has found.
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