THE Deputy State Coroner has referred a "known person" to the Director of Public Prosecutions in relation to the death of Grafton jail prisoner Ian Klum in June 2010.
The Coronial inquest into Mr Klum's death resumed in Grafton today after it was adjourned in August to allow time for leading investigator detective senior constable Doug Scott to speak to a former prisoner whom, it was suggested, police had not yet interviewed.
Under questioning from Counsel assisting the coroner Kirsten Edwards, Detective Scott told the court that the former prisoner had been killed in an "accident" at Moonee on May 25, 2011.
Despite being given the opportinity, Detective Scott was not cross-examined by a former prisoner who attended the inquest today.
Parts of the short proceedings today, including the identities of certain witnesses, were the subject of a non-publication order but Deputy State Coroner Malcolm McPherson made a formal statement on the matter before suspending the inquest indefinitely.
Mr McPherson said he had formed the opinion that the evidence presented to the inquest was capable of satisfying a jury that a "known person" had committed an indictable offence causing the death of Ian Albert Klum in June 2010.
On this basis, Mr McPherson referred the matter to the office of the DPP which will now have to make a decision whether it will formally charge a former prisoner over the matter.
He conveyed his sympathies to Mr Klum's family for enduring three weeks of the inquest thus far.
Ms Edwards said the inquest was likely to resume after the matter had been dealt with by the DPP.
This was expected to occur, she said, regardless of whether the DPP decided to proceed with charges or not.
Mr Klum's family said they were concerned the inquest would not hear extensively from the final two witnesses - Detective Doug Scott and Corrective Services investigator Simon Berry.
Mr Klum's ex-wife Peta Hines said the family wanted to see these two witnesses cross-examined in the hope of answering questions that remained about Mr Klum's final few hours in the jail.
"Perhaps they will reveal information about access to computers or maybe someone watched some of the missing footage," Ms Hines said.
"It will be interesting to see what the DPP decides to do."
Mr Klum's family speaks out against his custodial sentence in tomorrow's Daily Examiner and asks why GP and psychiatric reports were seemingly ignored by the courts.
Mr Klum, who was serving time for traffic offences, died on June 14, 2010 when the pressure inside his skull from an "evolving subdural haemorrhage" became too much for his body to handle, the inquest heard during its first sitting in October 2011.
The case began with a "knock-up" or emergency call from cell 219 in Grafton Correctional Centre's multi-purpose unit at 2.29am on June 10, 2010.
The inquest has focused on the treatment Klum received from prison officers and medical staff after the "knock-up call" was lodged.
Sydney-based emergency medicine professor Dr Gordian Fulde told the inquest (via audio-video link) that Klum's blood would not have been able to coagulate because of its high INR (international normalised ratio) level of 3.9 - a level brought on by blood-thinning medication warfarin.
"If a patient had a raised INR, the blood wouldn't clot so a bruise keeps expanding and blood keeps thinning ... it's particularly nasty in the skull because the skull is like a closed box and nothing can expand."
The INR level, said Dr Fulde, should have caused concern for Klum's GP Dr Keogh who should have "energetically pursued" the case to get the level under control.
The court heard Dr Keogh had dropped Klum's warfarin dosage on about May 31 but no follow-up test had been done to check the levels - possibly due to a broken INR testing machine at the jail.
His INR level when he was taken to Grafton Base Hospital on June 10 was 4.3.
"Once the INR goes over 4, the risk to the patient exceeds any benefit they have from anti-coagulation and there is a greater risk of bleeding complications."
Prison officer David Pearcey told the inquest on Tuesday that he had heard Klum moaning while in the detox area and saying the words: "My head hurts, I want to go to hospital."
Mr Pearcey said that before cutbacks were made about two years ago, a registered nurse would be on shift to accompany officers on every knock-up call.
Justice Health Nurse Nerye White, who assessed Klum's medical condition about 3.20am after being called into the centre, said she had been told that Klum had been involved in an incident in his cell and she noted a small amount of blood under his nose.
Under questioning from counsel assisting the coroner Warwick Hunt, Ms White said officers did not inform her that Mr Klum had not been able to walk from his cell to another cell (he crawled) and then had to be assisted down stairs to the detox area.
Nor had they told her, she said, that Klum had complained of vertigo or a headache.
She said had she known these factors she would have called for an ambulance sooner.
Mr Klum was taken by ambulance to GBH after 6am.
The inquest heard earlier from prison officer Matt Barnett who told the court he meant no disrespect to Klum by repeatedly ordering him to get up and walk from his temporary holding cell.
Footage of the moments when Klum crawled across the floor between cells in the multi-purpose unit have been screened on the ABC's 7.30 Report and can be viewed in the video above.