Billy Bazouni was serving a three-year sentence for armed robbery when he died in 2016.
Now, six years later, a coroner is investigating the circumstances leading to his death, including whether health staff at Port Phillip Prison were told he swallowed the bag of ice.
Bazouni, who was 21, was placed in a unit for high risk prisoners after incidents including assaults on other inmates and staff.
About 6.15am on July 2, 2016 he told prison officers he was experiencing chest pains and having difficulty breathing.
He was seen pacing his cell with clenched fists and grinding his teeth. A guard suggested he looked "wired" but he denied taking anything.
A code black medical incident was called,and medical staff and tactical officers - who were required to transfer higher risk prisoners - moved him to the prison's hospital unit for assessment.
While Bazouni denied taking anything, prisoners said he had ingested ice.
It was decided he should be observed until the effects of an ice overdose wore off.
During a strip search - standard procedure for prisoners admitted to the inpatient unit - something dropped from Bazouni's groin area.
He picked it up and swallowed it.
It's unclear if medical staff were told.
A tactical officer told the inquest on Tuesday it was not his job to assess whether something was a medical issue, only to notify his supervisor.
Bazouni was moved to an observation cell and placed face down on the ground with a sheet over him. He could be heard groaning.
A nurse saw him breathing and moving but did not attempt to check his vital signs over concerns he could be violent.
At 8.20am the nurse noticed he was not moving and there was a pool of blood beside him. She immediately called a medical emergency and Bazouni was handcuffed before CPR began.
He regained a pulse and was rushed to hospital where he died four days later.
He had a significant amount of methamphetamine in his system which was "excessive and potentially fatal". Cause of death was a hypoxic brain injury.
Bazouni underwent surgery to remove a bag of ice from his stomach. The bag was sealed with a knot and the surgeon said there was no evidence any of its contents had leaked.
The inquest before coroner David Ryan is continuing.
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