Deaths in custody

Deaths in custody

Death of David Dungay Jr.

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(David Dungay's mother seen infront of the inquest: SBS)

Latest News

National Deaths in Custody Database Proposal
Meeting the Governor at Yabun
Prison Commissioner's response to recommendations
Report on Coroner's Decision and Recommendations 
Anticipation Coroner's decision: Next moves
JA Submission to Coroner
Family statement to media 8 March 2019
Report on Inquest last day 8 March 2019
Report on Inquest 4 March 2019
Report on Inquest 5 March 2019
Report on Inquest 6 March 2019
Report on Inquest 7 March 2019


David Dungay Jr, was a 26 year old Dungatti man, who died on December 29, 2015 in Sydney's Long Bay Prison Hospital. In an attempted cell transfer, Dungay had refused to stop eating a packet of biscuits. As a result, six guards held him down in a prone position, administering a sedative while nursing staff and four other guards looked on. He called out twelve times that he couldn't breathe before losing consiousness. By the time the guards realised the seriousness of the situation, several minutes had gone past before basic life saving support was attempted. Still, only two compressions were undertaken. Dungay had gone into asystole arrest, otherwise known as irreversible cardiac arrest. 

For the full story:The tragic death in custody of David Dungay

Justice Action's David Dungay project seeks to explore whether the NSW Coroner’s recommendations from the inquest into David’s death have been received on a national level and whether reforms have been made to implement these recommendations. Justice Action is interested in this project as the demonstrated indifference to David’s death proves a failure of the authorities, and continued inaction would only lead to further preventable deaths. Following our research into the issue, and the subsequent communication with national coroners, NCIS, Governor of NSW, and AIC, it has become clear current structure is lacking, and major reforms into the reporting and dissemination of key information for the prevention of future deaths in custody.

The findings of the 2019 Inquest into David Dungay's death includes numerous recommendations, provided under act 82 of the Coroners Act. Due to the lacking information infrastructure, we are finding that many states have had similar previous incidents without wide reporting, many of which could have been prevented, or could themselves have prevented David's death. We are currently sending the recommendations to all coroners offices, in an attempt to put into practice the necessary precautionary measures.



Initiate and achieve the establishment of a national database through which coroners share their findings, and publish responses; minimising any chance for further deaths in custody. To achieve this Justice Action has been in contact with the offices of all state and territory coroners, the Australian Institute for Criminology, the National Coroners Information Services, State Governors, Coroner's Courts and other responsible government departments. 

Media Links

The Guardian ran a series of ‘Behind the Lines’, ‘Breathless’ podcasts as well as articles specifically on Dungay’s death in custody:


Other Media Articles 

https://www.theaustralian.com.au/news/nation/moving-out-of-squalor-to-an-uncertain-future/news-story/f8479a188e3dc22799a0a2a76a5886de https://www.macleayargus.com.au/story/5426815/peaceful-protest-as-family-searches-for-answers/



Duty of care for complex health needs, forced medication & use of dangerous restraint (page 7)

Black Deaths in Custody in Australia
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Indigenous Incarceration is a national tragedy that demands action

Deathscapes - Mapping Racialised Violence in Settler States


Institutional Abuse & Discrimination, Coronial Inquiries

Amanda Dissel & Jody Kollapen, ‘Racism and discrimination in the South African Penal system.’  Penal reform International, 2003, NCJ number NCJ 206983  https://www.ncjrs.gov/App/Publicatins/abstract.aspx?ID=206983
Barbara Chambers and Jan Pettman, ‘Anti-Racism: a Handbook for Adult Educators.’  Human Rights Commission Education,  Series No. 1.   Australian Government Publishing Service,  Canberra, 1986.
Chris Owen, ‘Every Mother’s Son is Guilty: Policing the Kimberly Frontier of Western Australia 1882-1905.  UWAP Scholarly, 2016.

http: //www.uwap.uwas.edu.au   
Charles Reasons, ‘Racism, Prisons, and Prisoner Rights.’  Issues in Criminology, Volume 9, Number 2 (Fall, 1974), 3-20, page 3.

Need For Criminal/ Civil Liability
Peter Grabosky, Anita Scandia, Kayleen Hazelhurst, Paul Wilson, ‘Aboriginal deaths in custody’.  Australian Institute of Criminology: trends and issues, Canberra May 1988.L. v. Commonwealth (1976) 10 ALR 269; Howard v. Jarvis (1958) 98 CLR

Black Deaths in Custody - New York and Internationally


Duty of Care

Australian police and correctional services have a duty of care to all prisoners. This duty of care must ensure the safety of all prisoners, by ensuring their physical and mental health needs are met in a swift and effective manner to prevent harm to the individual or others. Tragic and preventable deaths in custody show the continuous failure of these services to effectively realise their duty of care. By highlighting cases where duty of care was not realised, Justice Action is pushing for accountability and change within correctional services. 

Miriam Merten was a mental health patient at Lismore Base Hospital. She died on June 3rd 2014, due to injuries she sustained during her time in seclusion. She suffered a traumatic brain injury after falling more than 20 times whilst in the care of NSW Health Staff. Her death was due to a failure of duty of care, and could have been avoided. 


Tracy Brannigan died of a suspected drug overdose in 2013 at the Dillwynia Correctional Centre. During her sentence, correctional service officers were aware of her drug use, yet placed her in an unsupervised ‘high needs’ cell with another known drug user and isolated her from the support of her friends and family. Tracy’s death could have been avoided if effective duty of care had been given. 


Frank Townsend was murdered by his cellmate, John Walsh, in January 2017 at the Long Bay Correctional Centre. According to a psychologist at the Lithgow Correctional Centre, Mr Walsh is a “serious threat” to any cellmate he may be placed with, and it was recorded on his file that he should remain in a single cell. Even further, Walsh himself claimed that if he were placed with a cellmate, he would “kill him or be killed by him”. Mr Townsend’s death could have been easily avoided if the Correctional Centre placed Mr Walsh in a single cell, and not forced him to reside with a cellmate. 

Access to Services

Individuals incarcerated within Australian correctional facilities often experience various physical and mental health issues. These issues can be exacerbated by the stress of incarceration. Prisoners must have access to services that will ensure they are able to improve and maintain their physical and mental wellbeing. These services can include, but are not limited to, mental health services, addiction rehabilitation services and Aboriginal support services. 


A 20 year old campaign we have been running is ‘Cells in Computers Initiative’ that presents the need for a computer to be placed in every cell. This will make our communities safer and more inclusive. Not only do computers promote self-improvement by encouraging education and vocational training, they also provide an effective tool to target recidivism. For individuals experiencing the prison system from the inside, a computer offers a means of communicating with family, dealing with boredom in a productive, safe manner and enabling access to crucial legal resources, especially considering the majority of prisoners spend around 18 hours a day in their cells.

Safe Restraint

Safe restraint means forcefully to limit a prisoner’s movement.  Despite the clear and specific guideline on when to use and which safe restraint method to use, it’s common for police to abuse their authority. Abuse of authority can even lead to death in custody or a conflict. 


This was the case for David Dungay Jr., a Dungatti man who died on December 29th 2015, due to a sudden inability to breathe. He was known to suffer from diabetes, asthma and developed mental health issues. Dungay Jr refused to stop eating a package of crackers before being held down by prison guards. Hospital records showed that he was not sent as soon as possible to a hospital that specialized in treating diabetes, as had been recommended by his medical supervisor. 


Wayne Morrison is a 29 year old who passed away 3 days after being in hospital due to spit hoods and also asphyxia. He was transferred from a prison to another due to overcrowding, four officers who were in the van did not give any explanation when being asked what they were doing. According to the CCTV recording, Morrison was wrestled by 12 guards and his hands and legs were cuffed at the same time. In addition to what the police did, Wayne was carried in the wrong position with his head facing downward, his chest was downward as well.   Mr.Morrison had no prior case before this one. This case could be avoided if police officers were trained in positions that could result in breathing difficulty.

International Stance of Deaths in Custody

The recent months of international protests and year-long campaigns have shown the issue of deaths in custody as not limited to Australia and its correctional services. Throughout the world there are endless cases of avoidable deaths in custody that need to be addressed. 


In the United States, many have been demanding answers for arrest-related deaths for many years now. In 2013, Congress passed the Death in Custody Reporting Act that requires states to present quarterly reports on deaths in police custody to address the lack of reliable information around deaths in custody. However, Congress has failed to implement it, as states are not reporting, and so data has not been gathered nor been made public since the law was enacted. 


As there is an absence of a government database, other organisations have attempted to create their own including Fatal Encounters, created by the former editor and publisher of Reno News & Review, and the Washington Post national database. It has also raised concern from various members of parliament. 


“The United States continues to face a persistent crisis of deaths in custody, the true scope of which remains unknown” - Jerrold Nadler, chairman of the House Judiciary Committee, and Karen Bass, chairwoman of the House Subcommittee on Crime, Terrorism and Homeland Security


A study conducted by academics at the University of Oxford found that both Nordic Countries (excluding Denmark) and Western Europe had the highest prisoner suicide rates of more than 100 suicides per 100,000 prisoners. It conducted as prisoner suicide rates needed clarification and updates, and concluded that “individual-level information about prisoner health [was] required to understand the substantial variations reported and changes over time.”


In addition to this, 2017 reports about England and Wales find that their death rates are considered low when compared to the limited international data. In the last 10 years, 163 people died in or following police custody, according to figures from the Independent Office for Police Conduct (IOPC). Suggested reasons for their success are that the following interventions were proposed, though not fully implemented by correctional services:

  1. Alternatives to policy custody for vulnerable individuals who are intoxicated or have mental health needs;
  2. developing better screening and assessment tools to identify risk upon entry to police custody;  
  3. further training for relevant staff and health care professionals;  
  4. using technology to help monitor detainees; and  
  5. designing safer cells


Assessing different countries' response and actions to deaths in custody can help us understand the problem from a more global perspective. It is particularly useful to look at other countries that have  successfully implemented measures, which have proven to effectively reduce numbers of deaths in custody. These measures can be applied globally to ensure an international reduction of deaths in custody.

Death of Wayne Fella Morrison

Wayne Morrison interview


Wayne “Fella” Morrison, was a 29-year-old Wiradjuri, Kookatha and Wirangu man who died in hospital at 3:50am on the 26th of September 2016. Mr. Morrision was involved in an altercation three days prior to his death that resulted in him being pulled unconscious from the back of a prisoner transportation van. He did not receive immediate resuscitation and it took 50 minutes for medical services to arrive.

On the 23rd of September 2016, Mr. Morrison was due to appear in the Elizabeth Magistrates Court. However, following an altercation with two guards in his holding cell, he failed to show at the proceedings. At the time of his death, Mr. Morrison was on remand after being refused bail by an Adelaide court. This was his first time in custody, and he had no recorded criminal convictions.

CCTV footage shows that Mr. Morrison was wrestled to the ground in the corridor with up to 12 guards restraining his hands and legs. A group of 8 prison guards proceeded to place Mr. Morrison in the back of the prisoner transportation van in a ‘prone position’ (chest down, face down). A spit hood was placed on his head, despite an officer stating it looked like he was just trying to clear his throat of blood and saliva.

There were 4 guards present in the back of the van for the three and a half minute drive. There was no CCTV footage to document what occurred during the drive, and these 4 officers have refused to give statements about the incident. Upon arriving at their destination it was discovered that the guards failed to realise that Mr. Morrison was unconscious, and only commenced CPR two and a half minutes later. Furthermore, the defibrillator in the prison was broken, which is not compliant with the duty to maintain up-to-date defibrillators in the prison.

Experts believe that psychological and physical stress, physical restraint, and positional asphyxia in respect to how he was transported contributed to Mr. Morrison’s death. Positional asphyxia occurs when a person has been restrained in a way where they are unable to breathe - a key issue in the NSW inquest into the death of Dunghutti man David Dungay. Asphyxia relating to the spit mask was also noted as a contributing factor and may have been exacerbated by the fact that the spit mask was not placed correctly on Mr. Morrison‘s head. Despite an officer noticing this error, nothing was done about it.

The use of spit hoods has been banned or heavily restricted in Australia following Mr. Morrison’s death and Dylan Voller’s case, which prompted the Royal Commission into the Protection and Detention of Children in the Northern Territory. At the time of Mr. Morrison’s death, South Australia was the only jurisdiction in Australia where spit masks were still being used, until they were finally banned in 2019.  Additionally, when Mr. Morrison was in prison, the Aboriginal Legal Service was unable to contact him or organise a meeting since there was only one Aboriginal Liaison officer. 

Furthermore, the coronial inquiry was only scheduled to take place across three or four weeks, but has been delayed since late 2018 following two months of proceedings. Currently, they have only proceeded to the third sitting. Since the inquiry began, the Morrison family’s lawyers have pushed a claim that the coroner presents a biased judgement as she had previously represented parties employed by the Yatala prison when she was a barrister. However, the Supreme Court has dismissed this case.

As an outdoorsman, a fisherman and a painter of Indigneous art, Wayne was highly regarded as an incredibly gentle man whose spirit was broken by the prison system. The disproportionate rates of Indigenous incarceration and the systemic issue of black deaths in custody have risen, as 432 Indigenous Australians have died in custody since 1991.

“At the time of the 1991 Royal Commission into Aboriginal Deaths in Custody, Aboriginal people accounted for 1 in 7 deaths in custody. That number has now soared to 1 in 4.”, said his sister Latoya Rule. This in turn calls for systemic change in the prison system across Australia, following the Black Lives Matter Movement in the United States, with the purpose to stop the deaths in custody. The recommendations from the Royal Commission should be updated to reflect developments, such as in South Australia where the Custody Notification Service Bill was passed to notify Aboriginal Legal Rights when an Indigenous person is arrested.

Back to Deaths in Custody

Tane Chatfield Inquiry Report - NSW Coroner’s Court - 17/7/2020

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Today the Court began by hearing from the family of Mr. Chatfield to provide personal insight into his character. 


The Court heard statements from Mr. Chatfield's grandmother, sisters, brothers and friends who all quoted his good character as a protector for his family. The intergenerational trauma mentioned and made visible demonstrated the tragic and lasting effect Mr. Chatfield's death has had on his extended family. 


Both his younger sisters spoke of his caring and protective instincts and lamented that their children would be without their uncle. His younger brother shared that he wanted to be just like his older brother and pursue a football career. However, since his death in custody he has carried pain, anger and emotions that he has little control over. All family members spoke of the injustice Mr. Chatfield received and how greatly it still affected them. 


"The pain is still the same, and it doesn't help that the family has no answers".


Following this, a video prepared by the family was submitted with statements from his partner and further family members and friends. His partner said the charges he was on remand for were false and that he was with her on the night of the event. She explained how he took her in in times of hardship and was saddened that their child would grow up without their father. His other sisters spoke of his easy going and joke-ish behaviour and said he was a 'class clown'. He was also known in the family as 'the Golden Boy'. His older brother then spoke of his relationship with Mr. Chatfield, explaining how Mr. Chatfield was like 'his shadow' and how he still looked over his shoulder expecting him to be there but knowing he won't be. He also regretted the missed opportunities to tell Mr. Chatfield how much he cared for and loved him. His family continued to speak of the lasting trauma of his death and how they did not like speaking of him in the past tense as they did not want to believe he was really gone. 


Another prepared video was then shown with family members sharing what Mr. Chatfield had told them about his time in prison. His partner stated that he regularly called her and explained how he would be 'bashed by the screws and put in segro', sharing the lack of protections and decency shown to him by the correctional system. His sister shared this sentiment and explained that each time Mr. Chatfield was released from correctional services he was different. He was angrier, less social and less responsive to authority. The other statements shared that correctional officers and the correctional system were uncaring and often abusive to prisoners while neglecting rehabilitation efforts. 


After a short break, the Court heard the findings and recommendations of assisting counsel Ms. Stevens. Ms. Stevens spoke on the facts of the case in a chronological order. From the period of July 2015 to October Mr. Chatfield was in and out of custody. He returned to custody in October 2015, where he remained until his Death in September 2017.


Reflections were made on his youth experiences in the justice system and how he was flagged as vulnerable within the juvenile detention sector. He undertook the Justice Health Reception Screening Assessment and received a high rating of 45/50. Despite this score indicating high levels of stress and concern, Mr. Chatfield never received treatment.


Upon his return to custody for the final time, the Court heard how Mr. Chatfield expressed concern that his partner was not informed of his return to custody and that his son was something to live for. It was reported he was placed on a waiting list to see a psychologist, which was later fulfilled. 


In 2016, Mr. Chatfield tested positive for drugs in custody. It was said by Ms. Stevens that Mr. Chatfield continued to use drugs in custody and additionally suffered dental issues. On September 2nd 2017, after a family visit, Mr. Chatfield was found in possession of drugs and providing drugs to inmates. On September 17th, Mr. Chatfield tested positive for drugs.


On the 19th of September, Mr. Chatfield attended court and was reported to be in good spirits. Upon his return he was separated from his cell mate Darren Cutmore who he was said to be very close to. Mr. Chatfield was then placed in a cell with Barry Evans, who was in his first night of custody. 


The Court reported that two main events happened on September 19th. At 12:10pm Mr. Chatfield knocked up in his cell stating he was unwell and requested panadol. Ms. Stevens gave evidence to state that Barry Evans observed Mr. Chatfield partaking in fishing with Darren across the corridor between 10:27-10:41pm. Barry noted in his witness statement that he thought it was unlikely Mr. Chatfield engaged in drugs. At 11:04pm Barry Evans knocked up from his cell after Mr. Chatfield had suffered a seizure and was lying on the floor. 


Mr. Chatfield was taken from his cell to the clinic. It was reported that he suffered post elliptical confusion, as he was dazed and needed help to walk. Mr. Chatfield suffered a second seizure under the supervision of the guards, and he reported to medical officials that he suffered epilepsy, however there were no doctor records to support this diagnosis. 

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Mr. Chatfield underwent a neurological examination and returned normal signs. It was reported that Mr. Chatfield sought drugs whilst in hospital and rated his pain 10/10. He was recommended a General Practitioners follow up and discharged from the hospital, but he was not provided a discharge summary which was considered “very unfortunate” by Ms. Stevens. 


Between 7:45-8:00am Mr. Chatfield was escorted back to the centre. It was reported he could walk unaided. Ms. Stevens noted that there has been a dispute between information on whether the Nurse Unit Manager Ms. Adams knew about the seizures, as she claimed she did not know Mr. Chatfield had suffered a seizure and would have acted differently. 


It was noted that the nurse should have been aware of Mr. Chatfield's condition. Ms. Adams did not have the proper qualifications to hand out a sick cell order. Officer McFerson was not told why Mr. Chatfield was in his cell. At 8:17am officer McFerson told Mr. Chatfield he would remain in his cell until a discharge summary was provided. 


Between 8:17-9:05am a sweeper looked into Mr. Chatfield's cell and found him hanging in the back of his cell. Officer Smith reported he saw Mr. Chatfield hanging from the plumbing pipes. The officers cut Mr. Chatfield down and attempted resuscitations until the ambulance arrived. 


It was concluded that Mr. Chatfield committed suicide between 8:17-9:05am. He was admitted to the ICU and visited by his family. At 4:33 on the 22nd of September Mr. Chatfield was pronounced deceased. No foul play was suggested. It was concluded Mr. Chatfield died in Tamworth hospital as a result of hanging.


Ms. Stevens then presented the following recommendations to the Coroner:


  1. Corrective Services and Justice Health should regulate that any inmate returning from hospital be placed in a ‘Two-out cell’ or ‘Assessment cell’ until a full medical assessment by medical staff. If it is decided that the inmate will not be placed in one of these types of cells, it must be only with a full, documented reason.

  2. Aboriginal Health and Support Workers should be more readily available at Tamworth Correctional Facility in order to support Indigenous inmates in a culturally appropriate way.

  3. Tamworth Correctional Facility must require a discharge summary to be handed to and received by Correctional Officers at the hospital before they return the inmate from hospital to the Correctional Facility.

  4. All hanging points to be removed. There have been no compliance audits of hanging parts at Tamworth Correctional Centre.


Mr. Blackshield, the Chatfield family's lawyer, then presented submissions. He noted that there are over 100 pages outlining the disciplinary actions taken against Mr. Chatfield, who was only 22 years old. He emphasised one particular instance, in which correctional services found Mr. Chatfield guilty of smoking despite his denial and without any investigation. Furthermore, Mr. Blackshield noted that emails from correctional service officers naming Mr. Chatfield as a "target" for regular cell searches demonstrates the kind of attitude held by correctional service officers.


Mr. Blackshield then summarised the evidence supporting that Mr. Chatfield did not use drugs on 19th September, the evening before his death. He relied on the evidence of Mr. Chatfield's usual cellmate Mr. Cutmore, Mr. Chatfield's new cell mate Mr. Evans, evidence of Mr. Chatfield's admission to the doctor that he had taken drugs recently but not that night, and the absence of any indication in the post-mortem toxicology report.


Mr. Blackshield then listed a series of failures that took place in Mr. Chatfield's case:


  1. Failure to enrol Mr. Chatfield into a rehabilitation program, despite the officers' actual knowledge of his drug issues.

  2. Failure to notify his next of kin about his admission into hospital.

  3. No medical summary available to the doctor.

  4. No discharge summary given to the officers. 

  5. Failure of Ms. Adams to take Mr. Chatfield's medical history, to check her emails for the after-hours nursing sheet, to wait a few minutes for the nursing sheet to arrive.

  6. Failure to put Mr. Chatfield in a cell with other inmates. Mr. Blackshield later clarified that Mr. Chatfield could have been placed with Mr. Cutmore, or alternatively due to his popularity, the guards could have asked anyone in the yard to be in his cell with him.

  7. Failure of guards to allow Mr. Chatfield to make a phone call.

  8. Failure to read discharge summary. 

  9. Failure to call Mr. Chatfield back from his cell when discharge summary arrived.

  10. Failure to allow Mr. Chatfield to shower.

  11. Failure to allow family to run a smoking ceremony.


Mr. Blackshield stated that Ms. Adams knew Mr. Chatfield would be alone in his cell, and told the officer it would be okay to send him into the cell alone. She admitted during the inquest that she would not have done this if she knew about the seizures. She also made no effort to follow up on the discharge summary. There was no indication that leaving Mr. Chatfield alone in the cell was safe.


Mr. Blackshield's proposed findings were:


  1. Mr. Chatfield's death be ruled a suicide induced by extreme anxiety and stress, withdrawal from drugs and postictal psychosis.

  2. There were failures to prevent Mr. Chatfield's suicide, including a failure in the duty of care over Mr. Chatfield when he was locked in an effectively unobservable cell alone.


Mr. Blackshield's recommendations were:


  1. For Correctional Services NSW to update their policy to ensure next of kin are not only notified when inmates go to the regular admission at the hospital, but also when they go to the emergency admission

  2. That Correctional Officers not return a discharged inmate from the hospital without a discharge summary from the hospital being provided in person at the point of discharge.

  3. That if an inmate has been discharged from hospital, they are kept in a ‘Two-out’ cell until a full medical assessment is completed. 

  4. For Indigenous liaison officers to be available at correctional centres, especially in Tamworth 

  5. For Indigenous status to be included as a mitigating factor in criminal sentencing

  6. For Indigenous status to be taken into account when judging bail applications

  7. To allow inmates to contact their next of kin on return from the hospital

  8. To allow inmates to take showers following hospital visits unless there is a substantial reason not to

  9. To provide education services to ensure inmates had access to different activities other constant drug use

  10. To ensure rehabilitation services are readily and widely available, especially for drug users

  11. Nurse Adams to be referred to the relevant professional medical conduct board for misconduct in her treatment of Mr. Chatfield

  12. The absolute removal of all hanging points in all correctional services in the state which has been the subject of many previous inquests


A spokesperson acting on behalf of Justice Health and Mental Health Network NSW then presented their findings and recommendations for the coroner. 


The spokesperson firstly, on behalf of Justice Health, admitted that Mr. Chatfield was not given appropriate care after his admission to hospital. He then apologised on behalf of Justice Health and himself to Tane’s extended family who were present.


He then presented the following recommendations, which concurred with recommendations given by Ms. Stevens and Mr. Blackshield:


  1. That it be required for discharge summaries to be given to Correctional Officers before an inmate is discharged from hospital to return to a correctional facility. 

  2. That if an inmate has been discharged from hospital, they are kept in a ‘Two-out’ cell until a full medical assessment is completed.


The spokesperson then continued to explain that Mr. Chatfield had been assigned a ‘normal’ cell placement status at the time of the incident and the two years before. This referred to the fact that, before hospitalisation, he was not marked as having to be kept in a ‘Two-out’ cell due to medical or mental health conditions. He posited that Kessler Psychological Distress Scale (K10) scores cannot be given too much weight in assessing suicide risk, and that particularly in Mr. Chatfield’s case, they varied rapidly, fluctuating from between scores of 10 out of 50 (the lowest possible score, indicating the least amount of psychological distress or paint), to 45 out of 50 (a very high score indicating severe distress) in a matter of days.


He outlined that in September of 2017 Mr. Chatfield had no signs of recent self-harm on his body, and that there were none since his self-harm in 2015, at which point he was outside of correctional facilities. Further, there was no history of epilepsy or seizures known to Justice Health NSW regarding Mr. Chatfield before his death. It was as a result of this that he had been placed under ‘normal’ cell placement status, and had been since 2015.

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The spokesperson continued, saying that Ms. Adams’ assessment of Mr. Chatfield at 7:55am on the 19th of September 2017 was that she felt he was ok, and that she did not observe symptoms of Mr. Chatfield being in a Postictal state. Because she was unable to see the discharge summary, there was not other evidence to suggest she should believe he was in any other state. At this point however, the Coroner interjected to comment that she believed Ms. Adams, during her testimony, had said that at the time of the assessment she was not aware of the concept of a Postictal state. The Coroner then inquired as to whether it was necessary that extra training be given to medical staff in corrections facilities, because of the frequency of seizures in such facilities. 


The spokesperson for Justice Health then laid out how Corrections Officers thought that the time that Mr. Chatfield would spend in the cell alone would be very small. He continued that Ms. Adams delegated the next nurse on duty to obtain the discharge summary as a matter of importance. Furthermore, he posited Ms. Adams was frankly unaware of Mr. Chatfield’s seizures, and that she thought that Mr. Chatfield wouldn’t have been discharged from hospital unless he was suitable to be returned to the corrections facility. 


The Coroner then interjected, stating her concern in the lack of curiosity by Ms. Adams in such a situation, inquiring as to why she wouldn’t have checked for more information from Mr. Chatfield himself. To this the spokesperson replied that Nurse Adams thought that the requests for an EEG and the prescription for Endone on Mr. Chatfield’s current medical record were conflicting and confusing, and that she desired to wait for a professional medical explanation in the form of the discharge summary to find such answers. With the spokesperson laying out the discharge summary arrived at 8:20am but was not read until much later, and the Coroner explaining that she saw that fact as a failure of Justice Health NSW, this presentation finished.


A Mr. Evans, representing NSW Corrective Services, then presented their findings and recommendations to the Coroner. 


He began by expressing that he hoped the footage of Corrective Officers rushing to Mr. Chatfield’s cell, the officer cutting him down from the noose, and the attempts to resuscitate Mr. Chatfield would be seen as evidence of NSW Corrective Services’ desire to care for Mr. Chatfield.


Following this, Mr. Evans brought up the Corrective Services NSW’s findings to several issues in the case:


  1. That the response of Corrective Officers who responded to Mr. Chatfield’s medical emergency on the night of his seizures, including calling an ambulance, was appropriate

  2. That because Corrective Services was not advised by Justice Health NSW to put Mr. Chatfield in anything other than ‘normal’ cell placements, and because Mr. Chatfield was not showing mannerisMs. of increased risk on the morning of the 19th of September, it not not the fault of Corrective Services that he was placed in a cell with hanging points

  3. According to Corrective Services regulations the decision by Ms. Adams to categorise Mr. Chatfield as ‘sick in cell’ did not mandate a nursing certificate at the time of the incident, and as such there was no wrongdoing in her lack of completion of such. Mr. Evans noted that this policy has been changed since to require a nursing certificate upon that categorisation. Furthermore he noted that on the balance of probability it was likely that Nurse Adams had been told that Mr. Chatfield had been to hospital because he had a ‘fit’, or something close to that nature.

  4. Corrective Services agreed on the recommendations regarding discharge summaries to be mandatorily collected by Corrections Officers when returning discharged inmates from hospital.

  5. That there are practical limitations regarding removal of hanging points from prisons in prisons. Mr. Evans cited funding and resource limitations as an example, pointing to the fact that possibly education or mental health services would have to be cut in order to free up funds for such changes. Furthermore he outlined that while there is not specific evidence of audits for hanging points, there has been some improvement in their removal.

  6. That Corrective Officers responded in a timely, appropriate, urgent, and skilful manner to Mr. Chatfield’s hanging, as evidenced by their rushing in, cutting of the noose, and administering CPR.


Mr. Evans also outlined that Corrective Services NSW supports the recommendation to mandate all inmates discharged from hospital be placed in ‘Two-out’ cells until a full medical assessment has been completed. He also said that Corrective Services support (in principle and without instruction) more access to Indigenous support services in correctional facilities. 


At this point, the Coroner noted it may be important that Corrective Services NSW heed the recommendation made by other parties to change their policy to notify inmates’ next-of-kin when they enter emergency admission at hospital.


Mr. Evans then denied that Mr. Chatfield was unfairly treated by Corrective Services at any point during his time in the justice system under the care of Corrective Services. 


The Coroner then adjourned the Court for findings, to be presented in Armidale court on the 26th of August.


Justice Action believes there is clear negligence and a breach of established duty of care by Corrective Services and Justice Health. Below are detailed notes from each day of the inquest held Monday 13th - Friday 17th July 2020. The family of Tane Chatfield are desperate for justice.


Tane Chatfield Inquiry Report - NSW Coroner’s Court - 15/7/2020

The court heard further evidence from Ms. Adams, the Nurse Unit Manager, Officer McPherson, Mr. O’Leary, Mr. Dahlstrom and Officer Smith. 


As the proceedings from the 14th of July had already shown, Ms. Adams had grossly neglected her duties as a nurse. There were several protocols which could have, and should have been followed in the case of Tane Chatfield. Of the most importance was the neglect by Ms. Adams to complete a clinical assessment of Tane Chatfield. Her oversight in this regard left Tane Chatfield in a position where upon return to his cell, appropriate monitoring of his health was not performed. 


An issue was whether Ms. Adams could be compelled to give evidence, as it had been argued that her giving evidence would violate her right against self-incrimination. Ms. Adams was found by the Coroner to be in a position where her giving evidence was found to be in the interests of justice. However, she was granted a certificate of protection meaning her evidence could not be used against her in later proceedings. This certificate represents the systemic issue where incompetence, ignorance and disregard is not penalised and those responsible for it are not held accountable. Despite this certificate of protection, the evidence provided by Ms. Adams was limited and did little more than highlight her complete inefficiency and lack of care toward Tane Chatfield and the obvious structural problems within this particular medical facility. 


Following this provision of evidence, Ms. Adams offered an insincere apology to the Chatfield family which furthered the sense of disregard she felt toward Tane Chatfield. However, when asked by the coroner, she did agree that the presence of an Aboriginal health officer would be effective in improving the treatment and care of Aboriginal inmates. In Tamworth Correctional Centre, where over 50% of inmates are Indigenous, this should undoubtedly be adopted.


Ms. Adams was followed by Officer Stephen McPherson - The Assistant Superintendent of Tamworth Correctional Facility. Officer McPherson said that on the day of Tane Chatfield’s death he was concerned with ensuring enough staff were there to escort him back to his cell and did not inquire into his medical state or seek documentation of Mr. Chatfield’s current medical condition. Officer McPherson outlined that he spoke to Ms. Adams who inquired as to Mr. Chatfield’s whereabouts, to which he replied “locked in cell”. Officer McPherson claimed he was not concerned about Mr. Chatfield being in a cell alone as he knew he had been taken to the clinic by Officer Fittler and examined by the Justice Health Clinic. He also stated that Ms. Adams had recommended he stay in his cell and thus didn’t see it as his responsibility to seek documentation supporting this recommendation or any other forms of medical assessments relating to Mr. Chatfield’s medical condition. 


At 8:16am, Officer McPherson told Tane Chatfield he would have to remain in his cell despite Mr. Chatfield requesting to have a shower. Officer McPherson outlined that while Mr. Chatfield was angered by this refusal and raised his voice, he did not become physically aggressive or abusive in any way, yet was still denied the opportunity to have a shower. 


Officer McPherson also outlined that there was an option to have someone stay in the cell with Mr. Chatfield, and that this option would have been feasible to carry out as he was a popular inmate. The reasons as to why this was not done remain unclear. Officer McPherson then stated there was no further engagement with Mr. Chatfield following the exchange at the cell door relating to the shower, and that he had no concerns about the state of Mr. Chatfield’s mental health despite him having just had multiple seizures. 


Of major concern was the statement by Officer McPherson that correctional service officers do not get access to the medical files of inmates created by Justice Health, and that the next of kin are not notified of an incident unless an inmate is officially ‘admitted’ to hospital. Had officers had access to Tane Chatfield’s medical record, they would have known he suffered from seizures and it would have been unlikely that he would be left alone following this episode. In addition, despite him not being admitted to hospital and only remaining in the emergency department, not notifying his next of kin of what had occurred the night before his death is insufficient and deeply upsetting for the Chatfield family. It is clear that seizures are an example of significant medical concern. 


Mr. O’Leary followed Officer McPherson in court. Mr. O’Leary was a sweeper at the Tamworth correctional facility and was the person who first discovered Tane Chatfield hanging from the sewage pipe in his cell. Immediately after this was discovered, he ran to get assistance from officers as confirmed by CCTV footage. He was then placed in the yard while officers responded. His statement was brief. 


This was followed by another brief statement from Mr. Dahlstrom, a former inmate of Tamworth Correctional facility and family friend of the Chatfields. Mr. Dahlstrom was located in the cell next to Tane Chatfield. Mr. Dahlstrom also stated that he had told Officers that if Mr. Chatfield was ill he should be in the company of a second person in the cell yet this was not done. It was also revealed that Mr. Dahlstrom had spoken on the phone to a family member and stated “he done it by accident” which he then explained he believed this due to officers and inmates in Tamworth Correctional Centre stating this is what had happened. Mr. Dahlstrom reiterated that Indigenous inmates are treated differently to non-Indigenous inmates in correctional facilities, particularly in Tamworth where the majority of inmates are Indigenous. 


The final witness of the day was Officer Smith who has been a correctional service officer for 29 years. Smith stated that at 9am Mr. O’Leary had ran to tell Officers about Mr. Chatfield being unresponsive in his cell, and that he immediately ran to the cell and noticed Mr. Chatfield had material on the left hand side of his neck and was standing against the sewage pipe with his legs bent and face down. Officer Smith then cut the material loose and stated that Mr. Chatfield collapsed over his arm: he realised that the material was a loop, not a noose, and that Mr. Chatfield had no muscle resistance at all when the loop had been cut. Immediately after this, he began CPR upon failing to find a pulse, which he continued with assistance from other officers until paramedics arrived. This series of events were confirmed with CCTV footage of the incident that was shown to the court. Following the arrival of paramedics, Officer Smith ceased in activities relating to Tane Chatfield yet expressed sincere remorse about the incident which the Chatfield family have outlined they respect. Tane Chatfield’s mother also expressed she felt Officer Smith had been left in the dark regarding information on Tane’s condition.

Tane Chatfield Coroner’s Inquest - NSW Coroner’s Court - 16/7/20

The court heard evidence from expert witnesses, neurosurgeon - Dr. Neil Simon, forensic pathologist - Dr. Stephen Cordner, psychiatrist - Dr. Matthew Large, and Corrective Services employee Saffron Cartwright. 


Dr. Neil Simon’s testimony consisted of a medical analysis into Mr. Chatfield’s seizure and the appropriateness and reasonableness of the care and action taken towards Mr. Chatfield in the events leading towards his death. During the testimony the doctor discussed the findings of a pineal and basal cyst and their potential inducement of the seizure Tane experienced. He stated that, in his belief, the cysts were not highly relevant or of functional significance to Tane’s seizures as the identification of cysts in an individual is not a factor in diagnosing epilepsy. He also stated that the autopsy findings did not indicate that Tane had a neurological disorder, as a neurologically-based autopsy would most likely lead to incidental findings which may or may not be relevant. He did mention however that there remains a limited understanding surrounding seizure genesis within the medical field and thus no possibility was able to be comprehensively ruled out. 


Following this there was considerable discussion on the potential experience of a postictal period. The postictal period may have contributed to suicidal behaviour, as it has been found that individuals may experience a disturbed thought process following a seizure. The postictal period, however, is not a set timeline and varies for individuals. The doctor stated that the period of time Tane was kept in the hospital was the standard observation time of 8 hours, which covered the period any postictal symptoms or the manifestation of a psychiatric illness would have emerged. If none were observed within that time they would be deemed fit to be sent home as a delayed event of such nature would not be expected to occur. He also stated that postictal symptoms were not observed in Tane based on the audio-deficient CCTV footage he viewed, yet in the absence of postictal psychosis there remains a chance for suicidal behaviour. 


Questioning resulted in the finding that despite the risk of increased suicidality following seizures, supervision within NSW goals is only recommended to those that present with elevated psychiatric symptoms. There was also brief mention on whether discharge of the patient based on suicidality following a seizure would differ if the patient was living at home with others or living at home by themselves (being alone presents a higher risk), or in custody and isolated from others, as this would be comparable to being alone and therefore lead to the patient being at a higher-risk for suicidal behaviour. 


The use of an electroencephalography (EEG), which monitors electrical activity within the brain, arose many times during the testimony as a method to determine whether Tane was suffering from epilepsy. Dr. Simon’s view was that Mr. Chatfield’s seizure was not one of an epileptic nature and was likely a psychogenic drug withdrawal related seizure, despite the fact that Tane had previously suffered from seizures following discussion on the various inducements of seizures. He also acknowledged that the conclusion arrived at by the medical team on the day seemed reasonable given the information they had access to: although a different conclusion may have been reached had they had all the information that he was given following the events of Mr. Chatfield’s death. 


Subsequently there was some mention of withdrawal from the drugs buprenorphine and mirtazapine and resulting psychosis of withdrawal, however, Dr. Simon specified that this was not within his expertise and was consequently unable to discuss the matter. 


The notification to health personnel of previous self-harm was considered in relation to the existence of approximately 15 parallel scars ranging from 30-40 millimetres on Mr Chatfield’s left forearm with the longest closest to the wrist. Dr. Simon responded that it would have been an indicator of self-harm, however, that it was not right to assume that the forearm scars were automatically contributory to epileptic seizures. 


Some questions regarding the appropriateness, from a medical view, of policy and procedural actions that had taken place during the events of Tane’s death and medical ordeal beforehand arose during the testimony. Dr. Simon refused to answer as he considered these outside his expertise. 


Dr. Stephen Cordner took the stand next with a short testimony mostly consisting of agreeing with the reports and findings of Tane Chatfield’s death. He stated that, despite viewing the 38 sensitive pictures taken by the family of Mr Chatfield while he was in the Intensive Care Unit, his opinion that Mr. Chatfield died as a result of hanging and that there was no foul play leading to his death.


Dr. Michael Large was the third expert for the day, a psychiatrist who worked in the Prince of Wales Hospital. He stated from his report that he felt that the best way to reduce deaths in custody is to reduce rates of Indigenous incarceration. He was of the opinion that Tane did not suffer from a high-impact mental disorder at the time of his death, and said that it was likely Tane had a non-epyleptic seizure. However, he did state that Tane did have a substance use disorder as a polysubstance user, and that the opiate withdrawal Tane was experiencing would have been subtle to others, but had dysphoric effects on Tane. Dr. Large also noted various suicide risk-factors for Tane, such as gender, Drug withdrawal and history of suicidality, but noted that such factors were not predictive. 


A further set of questions led to Dr. Large stating that suicide is often an impulsive decision, and that death by suicide is not that well-linked to suicidal ideation, despite commonly held beliefs. Dr. Large also stated that Tane felt “quite alone”, and that the prison should have provided more therapy or staff engagement. Finally, he also emphasised the importance of removing hanging points in custodial settings as a crucial intervention that will save lives, stating that it should be a “universal precaution”. 


The final witness was from Corrective Services NSW (CSNSW) - Ms. Saffron Cartright. Initially, Cartright was reluctant to acknowledge that CSNSW would benefit from having more Aboriginal staff members, constantly trying to frame her answers around discussing existing programs and the dedicated staff that they have in place for Aboriginal people, like the Aboriginal Regional Corrections Officer, although many of these were spread across the region, not directly in prisons. The question itself put forward by the Coroner’s Assistant was instead directed more towards allowing more support systems for Aboriginal people within prisons, rather than what was already in place.


Justice Grahame seemed to be in disbelief that there had not been an audit of Tamworth Correctional Centre following Mr. Chatfield’s death, and that the hanging points were yet to be removed. The only memo on deaths in custody had occurred in 2010, and led to some facilities in certain regions implementing some of the suggested strategies. Similarly, since Tane’s death, only the cells with the exact same pipe had them covered, and two grills were removed, with no more comprehensive action taken. There had been 4 deaths in custody in Tamworth Correctional Centre since the 1980s. Cartwright did note that since Tane’s passing, CSNSW had set up an Aboriginal Steering Committee that helped organise more programs to help Indigenous inmates. Finally, Ms. Cartright found it difficult to answer as to why CSNSW had struggled to fill positions for those of Aboriginal heritage, denying it was tied to poor work culture or efforts.


The day focused primarily on expert witnesses discussing Tane’s seizure and the medical processes surrounding it, while also briefly examining a CSNSW Officer, focusing on policy and procedural questions.



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