The New South Wales coroner's court has found the death in custody of a Budjiti and Murrawarri man was preventable.
Mootijah Douglas Shillingsworth, 44, presented to Silverwater Prison medical clinic with an ear infection in January 2018.
He died a month later from an abscess in his brain.
Deputy State Coroner Joan Baptie, cited "missed opportunities" over many years of incarceration to specifically treat Mootijah's hearing problems and ear infections.
"During the course of this inquest, it has become clear that Mootijah's death was preventable," she said.
"It is hoped that by investigating this death, the insidiousness and perniciousness of ear disease, particularly within Indigenous communities, has been highlighted".
'He was left to die'
Outside court, Mr Shillingsworth's cousin-sister Ruby Dykes raised awareness of the disease.
"Otitis media, a common health issue in many Aboriginal communities... can be treated with antibiotics, but Mootijah's ear infection was not properly diagnosed in custody," she said outside court.
"It got untreated to the point... where he was left to die."
The coroner made four recommendations, including for work to be done on access for First Nations inmates to Medicare, and for a long-term plan be developed for culturally safe primary health care.
Mootijah Shillingsworth (far left), standing with family. Source: Supplied
There was also a call for reforms to Justice Health and Forensic Mental Health Network procedures to create greater awareness about ear diseases affecting First Nations people.
Coroner Baptie also recommended for the changes to be funded and given priority, given the prevalence of ear disease amongst First Nations people.
"It's reasonable to conclude that there is a high incidence of otitis media and related difficulties among Aboriginal persons in custody in New South Wales," she wrote.
Mootijah's family held a smoking ceremony outside the New South Wales Coroner's Court.
"If you just met him, you wouldn't get boo out of him," Ms Dyke said.
"But he loved having a yarn up once he got comfortable around people. We've searched our souls long and hard, asking how a simple ear infection could take him away from us.
"How can we accept that our loved one has died from a simple ear infection?"
