If police called an ambulance to take Rebecca Lyn Maher to hospital because of her level of intoxication, she would not have died.
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If officers who detained her on the roadside at Cessnock conducted even the most basic body search before they left her for hours in a cell, they would likely have found at least one of the two pill bottles containing a dangerous and addictive prescription medication discovered on her after her death.
If Maitland Police Station's acting custody manager had conducted proper inspections, he would have determined Ms Maher was so intoxicated that she had become either unconscious or had very low consciousness and could have called for medical attention.
And if police had made an effort to find Ms Maher a responsible friend or family member who could take her into their care, she would not have spent more than four hours locked up when she had not been arrested.
Those were among the findings from the Coronial inquest into the death of the Wiradjuri woman in police custody on the morning of July 19, 2016.
Acting State Coroner Teresa O'Sullivan handed down the results of the two-week inquest on Friday.
She found the mother of four's death was accidental - caused by respiratory depression after she lost consciousness because of mixed drug toxicity as well a possible aspiration of vomit.
Ms O'Sullivan's final recommendations largely involved increased education for officers and called on NSW Police to continue reviewing the circumstances of Ms Maher's death for training purposes.
But the 36-year-old's family said it was "a very, very sad day" and labelled the recommendations "meaningless".
They were angry the recommendations did not go further - they had wanted serious charges levelled at police over Ms Maher's death.
In a statement read by a support person outside court after the findings were handed down, the family said police involved in the detention of Ms Maher "ignored their most basic duty of care protocols".
"Had Maitland police taken Rebecca Maher to the hospital, which was closer than the police station, Rebecca would be alive today and caring for her children," the statement said.
"Rebecca was a vital and treasured member of not only her family, but her community."
In her findings, Ms O'Sullivan was heavily critical of police involved in the detention of Ms Maher - who was not arrested but held because of her level of intoxication.
She said officers involved breached protocol and requirements by failing to search Ms Maher, not conducting proper regular inspections while she was in the cell, not making a reasonable attempt to find an alternative to detaining her, not conducting a risk assessment and not getting the heavily intoxicated woman to hospital for a medical assessment.
It is clear to me that Rebecca was a cherished and much-loved member of her family who continues to be dearly missed.
- Acting State Coroner Teresa O'Sullivan.
Ms O'Sullivan said she accepted expert evidence that Ms Maher would have survived if she was taken to hospital early, as per police protocol.
She was scathing about the conduct of Cessnock-based Dr Gunendra Weerabaddana, who had never before treated Ms Maher but prescribed her Alprazolam - a Schedule 8 drug under the Poisons and Therapeutic Goods legislation - the day before she died.
The inquest heard he did not properly check her medical history and did not contact the NSW Health Pharmaceutical Regulatory Unit as required before prescribing the potentially dangerous drug.
Ms O'Sullivan described Dr Weerabaddana's conduct as "highly inappropriate" and has handed evidence from the inquest to the Australian Medical Council for further investigation.
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Ms Maher was found by Sergeant Nathan Brooks while walking along Wollombi Road at Cessnock with a companion in the early hours of July 19, 2016.
The inquest heard two other officers - Senior Constable Laurie Coleman and Senior Constable Elizabeth South - were called to the scene to take Ms Maher to Maitland Police Station.
She was not under arrest and her companion was not detained.
Police did not search Ms Maher before she was placed in an observation cell because of an incorrect belief that the 36-year-old had Hepatitis C and HIV and a fear of being infected.
The Coroner found that Maitland Police Station's custody manager that night, Acting Sergeant Gregory Hosie, did not complete the required risk assessment and failed to conduct the proper inspections that he was required to perform as part of NSW Police protocol between 1.25am and just before 5.54am, when Ms Maher was found dead.
The inquest heard Ms Maher had been taking prescribed methadone and had two bottles of Alprazolam pills with her in the cell when she died.
A post mortem found high levels of Alprazolam and methadone in her body, which the inquest found "could lead to respiratory depression and failure".
Ms O'Sullivan said the officers involved should have recognised Ms Maher's state of intoxication and sought "urgent medical assessment" - their failure to do so was another breach of requirements.
"It is dangerous to take the approach that [an intoxicated] person will or can sleep it off," she said.
Ms O'Sullivan condemned the fact that it took police more than six hours to notify Ms Maher's mother Debbie Small of her daughter's death and that it was not done by an officer with the rank of Inspector or above, as per NSW Police protocol. She called it "troubling".
"I am concerned about the manner in which this was handled, it was disrespectful," Ms O'Sullivan said.
"It is clear to me that Rebecca was a cherished and much-loved member of her family who continues to be dearly missed."
NSW Police issued a short statement in response to the inquest findings: "The NSW Police Force will consider the Coronial findings into the death of Rebecca Maher, and respond to any recommendations directed to the Commissioner of Police".
Ms O'Sullivan also recommended improvements to the NSW Police Custody Management System as well as more funding for the Aboriginal Legal Service's Custody Notification Service.
Earlier, about 30 people held a march from Civic Park to Newcastle Courthouse calling for "justice".
"The actions of the police on duty was in total contrast to all police protocols and policies," Ms Maher's family said.
"It was not the first time this police station has had negative impact on Rebecca's life and this time it was fatal."