Despite a prisoner being the colour of a corpse, a coroner has been told Otago Prison staff did not call a doctor.
Within 24 hours, the prisoner, Jai Davis, was dead.
One Corrections officer who gave evidence in the Coroner's Inquest in Duendin today said prison nurses were asked several times if Davis would be seen by a doctor.
A Corrections officer told the court that by Davis' third day in the cell, he was grey in colour, was scratching his arms, had sunken eyes, slurred speech and breath that smelt like faeces. But he said the nurse assessing him at the time said he was fine. But by the next morning he was dead.
Ann Matenga, the custodial services manager on duty, told the inquest that despite 22 years in the department, she didn't know a medical officer was a doctor - not a nurse.
Otago Corrections officer Christopher Dalton described the moment he knew Davis was concealing drugs.
"SCO O'Gormon saw prisoner Davis reaching under his suicide gown. While the staff were searching the prisoner, I found a small plastic ziplock bag under his mattress, which had the remains of a green leaf-like substance," Mr Dalton said.
Davis died in 2011, while in a special observation cell at Otago Corrections Facility.
Staff had intercepted phone calls, so knew he was coming into the prison concealing drugs internally.
"We had to assume that he had reinserted the remainder into his rectum, eaten it or managed to get it into the drain by the door in the cell," Mr Dalton said.
A nurse and Dalton had previously spoken to Davis about the risk of holding drugs internally.
"If he had any concealed inside him, it could burst and make him sick or kill him. I asked if he understood what I had told him. He said 'I have taken nothing and I had nothing on me'," Mr Dalton said.
Sixty witnesses will be heard for the case which is expected to last for two weeks.