A Melbourne underworld figure suffocated in jail after guards used tear gas and riot shields before kneeling on him as he lay face-down with his hands behind his back, a lung expert believes.
Hizir Ferman, 35, died at the medium-security Loddon Prison in Castlemaine during an operation to relocate him to the maximum-security Barwon Prison in July 2016.
The decision to move Ferman came after he assaulted two prison guards in his cell at Loddon, knocking one of the officer's teeth out.
Security and Emergency Services Group officers were called in for the job and gas and a dog unit were deployed into the cell before Ferman was restrained.
He was taken to a decontamination room where he became unwell, vomiting in the shower and losing consciousness.
Nurses were on hand but they could not resuscitate Ferman.
The official cause of death at autopsy was "undetermined" but a respiratory expert suspects Ferman was "progressively suffocating" while being restrained.
Associate Professor Louis Irving studied video of the incident, particularly footage taken in the shower room.
Assoc Prof Irving did not believe the tear gas played a major part in Ferman's death.
But he said the "prone position" in which Ferman was held would have made it difficult for him to breathe.
"In this case the prone position was accompanied by a shield over his head and pressure appeared to be applied," he said.
Ferman is in the shower room being restrained for about six minutes, a video from the prison showed.
When Ferman was later sat up he looked "floppy" and his skin appeared to lose colour, Assoc Prof Irving said.
"He's not yelling. He's not talking. He's not fighting. And people are standing, watching him."
There were three nurses present at the scene, along with specialist officers who were called in for the operation.
Assoc Prof Irving appreciated the tough position staff were in but said there was a "lack of urgency" in the room.
"There is a point in time where someone has to speak up and say 'this has to stop. There is a man in danger'."
Assoc Prof Irving said the resuscitation could've occurred sooner.
At the time of his death, Ferman was serving a jail sentence of six years and five months for multiple offences.
He has been linked to numerous Melbourne gangland figures.
The inquest, before coroner Rosemary Carlin, is expected to run for a week, investigating the cause of death, the force used by officers and the response of nursing staff.
