A coroner has lamented the "unsafe" circumstances a Canberra man faced in a NSW prison, which culminated in his death. Jonathon Hogan died by suicide in Junee Correctional Centre in February 2018. The 23-year-old was an Aboriginal man of the Wiradjuri, Ngiyampaa, and Murrawarri people. His father, Matthew Hogan, told The Canberra Times his son was a "happy-go-lucky kid" who loved motorbikes prior to his incarceration. "Every day you think of him. A motorbike goes past ... it just brings backs memories of Jonathon," Mr Hogan said. "We'll never be the same without him." A coronial inquest into Jonathon Hogan's death last week found there was "little doubt" he received "poorly coordinated and planned" mental health care in the lead up to his death at Junee Correctional Centre. Mr Hogan had a history of substance abuse and a psychiatrist formed the opinion he had paranoid schizophrenia in 2014. He had been taken to Canberra Hospital's mental health unit in July 2017 after he was arrested in the ACT and had self-harmed in police custody. Upon his intake at Junee on August 2, 2017, jail staff knew he had previously been on medication for depression and schizophrenia, and had a history of self-harming. They also knew he was un-medicated at the time. But NSW Deputy State Coroner Harriet Grahame said there appeared to have been a "complete lack of curiosity about the exact nature of his current symptoms", and Mr Hogan was left untreated for three weeks after his initial screening. The NSW Coroners Court heard such a delay was a "common occurrence" in 2017. Ms Grahame said there appeared to have been a "lack of curiosity and adequate investigation of collaborative sources of information" surrounding Mr Hogan's mental health. "Although [a nurse at Junee] knew that Jonathon had very recently attended a hospital in Canberra in relation to mental health issues, there was no real follow up about what had actually occurred there," she said. "[The nurse] told the court that she understood Jonathon had left before treatment so 'there's going to be no medical record to obtain'. Rather than pique her curiosity, this appeared to close a door to any further inquiry." Mr Hogan was prescribed antipsychotic medication on August 24, 2017, but his treatment was "principally based" on his self reporting, Ms Grahame said. Mr Hogan's treating psychiatrist increased the inmate's dose of the medication on August 30, but did not review him again until some six weeks later. The psychiatrist saw Mr Hogan a third and final time on November 8, 2017. "Reviews were rescheduled on four occasions before his death, but on each occasion cancelled," Ms Grahame said. Mr Hogan missed taking his medication on six separate dates between January 11 and 24, 2018, but the reason why went unexplored. He died on February 3, 2018, after he was left in his cell alone. The cell's structure risked self-harm, but Junee officers had little information to assess the risk it posed to Mr Hogan. "He needed to be seen and heard by someone who was able to get past his quiet facade and understand the nature of his significant symptoms and concerns," Ms Grahame said. "I am so sorry that Jonathon experienced such despair in circumstances which were unsafe for him. "In my view, the state failed to provide Jonathon with adequate care at a time when he was in great need." Ms Grahame recommended that GEO Group Australia, which operates Junee Correctional Centre, review its procedures for inmates with mental illnesses. She recommended the company examine its ratio of mental health treating staff, and consider creating at least three full-time equivalent Aboriginal health worker positions at Junee. She said she was somewhat heartened by evidence Justice Health had designed a more sophisticated mental health screening tool, and would be rolling it out to correctional facilities across NSW subject to "overcoming budgetary limitations". "[Mr Hogan] needed an advocate within an under-resourced system," she said. Ms Grahame recommended that GEO Group consult with the Commissioner of Corrective Services NSW to review Junee's cell structures and examine the utility of adopting an alert system for when inmates made a significant number of phone calls. Matthew Hogan said mental health should be taken "way more seriously" at prisons. "At the end of the day, [prisoners have] done what they've done, but they're not there to be treated like dogs," he said. "They're still somebody's brother, sister, uncle, nephew, niece, or whatever. They've all got family."