Deaths in custody

Deaths in custody

Tane Chatfield Inquest Report - NSW Coroner’s Court - 13 and 14/7/2020

On the 20th of September 2017, 22-year old Gomeroi and Wakka Wakka Indigenous man Tane Chatfield was found unconscious in his cell at Tamworth Correctional Centre after suffering multiple seizures. Two days later he died at Tamworth Base Hospital. Tane Chatfield’s death occurred due to the negligent actions of both Justice Health and Corrective Services, institutions that must be held accountable for their actions. Tane’s story is upsettingly familiar, yet another indigenous death in custody. 

Having been on remand and in custody for 2 years, Tane Chatfield’s father Colin Chatfield believed that his son was happy and confident of his acquittal in the near future. However Corrective Services in 2017 ruled Mr. Chatfield’s death a suicide by hanging with no suspicious circumstances. Nioka, Mr. Chatfield’s mother, and his family dispute this ruling significantly. Photographs taken by family in the hospital reveal that Mr. Chatfield suffered extensive injuries inconsistent with hanging. These injuries included scratch marks, bruising on his face, a broken jaw and nose, injuries that suggest his death was in fact very suspicious. 

The first day of the inquest saw evidence from Mr. Chatfield’s last cellmate, Barry Evans.

Previously, Tane Chatfield had been cellmates with the co-accused Darren Brian Cutmore but had been moved due to the obvious association. Mr. Cutmore reiterated the family’s perception of Tane Chatfield as happy and awaiting acquittal but noted his distress and frustration when the two were separated. Evans gave evidence that Mr. Chatfield was welcoming towards him, noting that he did not observe him using drugs. Evans told the coroner that he called for assistance when he saw Mr. Chatfield hit the floor and looked “like he was having a fit”.

On the 17th, evidence was given by several staff members, including two correctional officers; Officer Chrome and Officer Fittler, and a Justice Health Nurse Unit Manager, Janeen Adams. Examination the witnesses revealed several significant concerns regarding negligence and duty of care of both Corrections and Justice Health.


On the 19th of September, Mr. Chatfield had two seizures and was taken to Tamworth Hospital accompanied by several officers including Officers Chrome and Fittler. Officer Fittler told the court that when Mr. Chatfield was discharged they did not receive nor ask for a discharge summary, an essential document detailing to the health and needs of Tane Chatfield. The absence of the discharge summary is proving an essential component of this Inquest.

Officer Fittler told the court that once they arrived after Mr. Chatfield was discharged, and he took him to the Justice Health Clinic to be observed by Nurse Unit Manager Janeen Adams. In the exchange, Officer Fittler detailed the medicine that Mr. Chatfield was given at hospital and that he needed an EEG. Nurse Adams told the court that she was not informed of his seizures the night before by Officer Fittler, which significantly affected her clinical assessment of Chatfield. In the clinic, Nurse Adams told the court that she briefly reviewed Mr. Chatfield and had no concerns for his health despite failing to view his discharge summary, take his history and review the after-hours nurse manager report. Her misinformed clinical assessment ultimately led to the death of Tane Chatfield.

Nurse Adams was negligent: she failed to attempt to source the discharge papers and read the after-hours nurse manager report and most importantly take a simple history of Mr. when he was presented to her. Nurse Adams advised Tane being taken back to his cell under the ‘sick in cell policy’.

Importantly, Nurse Adams admitted to the court that had she known the details of Mr. Chatfield’s condition from the discharge papers and the after-hours nurse manager report, her clinical assessment would have been different. Perhaps if the care of Tane Chatfield was not overlooked, he would not have died in custody.


Death of Tane Chatfield

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.

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Tane Chatfield Inquest Report 13 and 14/7/2020
Tane Chatfield Inquest Report 15/7/2020
Tane Chatfield Inquest Report 16/7/2020
Tane Chatfield Inquest Report 17/7/2020


Tane Chatfield, was a 22 year old Gomeroi and Wakka Wakka man, who was found unconscious in Tamworth Correctional Centre on the morning of 20th September 2017. He died 2 days later after being on life support at Tamworth Base Hospital. Corrective Services NSW conveyed that there were no suspicious circumstances regarding his death and that he attempted suicide via hanging in his cell.

His family believes more could have been done to prevent his death. Tane suffered two seizures before he was taken to Tamworth Base Hospital. Though the hospital was only 250m away, it took 40 minutes to get Tane to hospital. After he was discharged, the officers that accompanied him did not receive or ask for a discharge summary - an essential document regarding the health of Tane.

Tane was then taken to the Justice Health Clinic for further assessment. Because Tane’s health history was not appropriately assessed by the Nurse Unit Manager Janeen Adams at the Justice Health Clinic, he was sent to his unsupervised cell alone where he committed suicide. In the absence of advice, Tane was placed in a ‘normal’ cell which contained hanging points. These are still yet to be audited by Tamworth Correctional Centre following his death. Importantly, Nurse Adams admitted to the court that had she known the details of Tane’s condition from the discharge papers, her clinical assessment would have been different. Evidence suggests that if the care of Tane wasn’t overlooked, he wouldn’t have died in custody.

According to Dr. Neil Simon, his seizures were most likely due to psychogenic drug withdrawal. 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 Tane’s death.

Tane’s father Colin Chatfield exclaims that his son was confident of being acquitted in relation to the charges he had been on remand for two years for. This was the result of eight witnesses failing to identify him as being involved in the home invasions conducted in northern NSW in 2015. Furthermore, Tane’s family had also taken photos of his body in the hospital, which highlighted that Tane had suffered extensive injuries. Upon reflection of these images, NSW Greens MLC David Shoebridge remarked that Tane’s death was inconsistent with a hanging as the images showed skin under Tane’s nails, scratch marks on the body, bruising along the face, a busted lip and a broken nose and jaw.

This in turn has resulted in Tane’s death being counted as the 16th Aboriginal death in police custody since 2008, as per the Guardian, while corrective services highlighted this was the first Aboriginal ‘suicide’ in custody since 2010.

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Responses by authorities to Deaths in Custody Database Proposal

The proposal was distributed to authorities with oversight as well as those with direct coercive powers across Australia.

These included Coroners, the Australian Institute of Criminology, the National Coronial Information System, Attorneys-General, Governors, Health, Police and Corrective Services Commissioners.

Responses have been varied, and will be published in detail shortly. The Coroners were generally supportive. In WA, the Health Department is referring it to its special Committee to consider. Others resisted going outside of their area of direct obligation, despite their clear need to do so.

The National Coronial Information System (NCIS) responded to our proposal. It is funded to work closely with the Australian Institute of Criminology (AIC) to deal with Coronial information. We were disappointed with the response we received from the NCIS, and their lack of interest in improving the current system. They said they rejected the proposal and used spurious reasons. They said they already have a database, have no mandate to monitor court processes or outcomes, and don't form part of the coronial process.

Those reasons are ill-considered responses to our proposal. Their resistance demonstrates a systemic failure to protect the lives of those in custody. It is evident that the current system is not working as it should. The NCIS fails its funded function of preventing death and injury, and has no interest in doing so. See their letter and our response. We have proposed that its Board have a majority of members who represent people who are directly affected by deaths or injuries, rather than represent authorities and have a conflict of interest.

We will continue to lobby authorities for structural change, to prevent deaths in custody caused by the use of unsafe practices of restraint, as a legacy to the memory of David Dungay.
David Dungay Index page   Proposal


National Deaths in Custody Database Proposal

David Dungay was killed in the Long Bay Prison Hospital in 2015. He was held down onto his stomach by a six-member Immediate Action Team with knees on his back. His repetition of the words, “I can’t breathe,” echoes the cries of George Floyd and defines the callous approach taken by some authorities with coercive power. The disregard for the cries of a dying, vulnerable man provides insight into the practices used in some of the darkest corners of the country, where no one sees what happens.

The name of this restraining technique is called the ‘Prone Position.’ It had already been identified as fatally dangerous following the 2009 death of Robert Plasto-Lehner in the Northern Territory. Regardless, the same technique was used on David Dungay in New South Wales six years later. Recommendations by Coroners to stop that form of restraint were never sent to authorities in other jurisdictions, so the deadly practice has continued with no change in training.

See full proposal. 

See David Dungay Index page 

See Petition to support work 

This is a proposal for a new database system to include coronial findings on deaths in custody and recommendations from all Australian jurisdictions. It should be distributed nationwide with the responses from state and federal authorities who are affected by the recommendations. 

See responses by authorities.

Coroners’ Inquests into Robert Plasto-Lehner’s death (Northern Territory 2009), and those of Carl Antony Grillo (Queensland 2011), Bradley Karl Coolwell (Queensland 2017), and Pasquale Giorgio (Queensland 2018) reveal that in each of these cases, the causes of death were the result of being restrained in the prone position. This led to eventual suffocation from positional asphyxia. Further deaths in similar circumstances could have been avoided had the information, and possible strategies for reform, been implemented across jurisdictions.

The current coronial systems across all Australian jurisdictions present significant gaps in the collation, accessibility, dissemination and response by affected authorities of coronial reports. The Dungay family, and the wider community, stress the urgency of using the available information to prevent death.

In discharging their duties, the Coroner bears the obligation to prevent further deaths from occurring. At present, the Coroner makes recommendations for reform which are distributed to the affected authorities in their state. These reports are made available on separate coronial databases. The inclusion of government responses varies, with Queensland being the only state that specifies whether a response was required.

Data from the inquests is examined by two organisations; the National Coronial Information System (‘NCIS’) and the Australian Institute of Criminology (‘AIC’). The NCIS is intended to serve as a centralised database of deaths in custody, which includes some Coroners’ findings and recommendations. However, it is not updated regularly and has restricted access. The compartmentalisation of information leads to each Coroner existing within their own silo. This is contrary to the Coroners’ purpose of preventing further death.

The proposed database should utilise a clearinghouse model to create one central agency for information collection, classification, and distribution. The data would be collated and automatically distributed to all relevant government authorities, while also allowing for public access. It is crucial for it to be regularly updated, and require government responses to inquests, which will be searchable by catchword and report content.

It is proposed that the implementation of such a national database and follow up functions be facilitated by the NCIS and/or the AIC. The implementation of the proposed database would promote accountability among government authorities to address recurring issues that endanger the lives of incarcerated individuals. It is clear that by inducing collective learning, accessible solutions can be developed to prevent needless deaths across Australia. 

See petition to support work.


Report on Coroner's Decision and Recommendations

On December 29 2015, David Dungay Jr died in Sydney’s Long Bay Prison Hospital after being violently manouvered by corrective service officers, held face down and sedated because he refused to stop eating a rice cracker.



Today, the coroner’s findings and Recommendations into the death of David were revealed. Outside the NSW State Coroner’s Court at Lidcombe stood the 26-year-old Dungatti man’s family members and supporters who shouted “You say accident, we say murder” as they waited for NSW deputy coroner Derek Lee to present the state’s findings on his death. By 10am, Courtroom 1 overflowed with David’s family members, legal personnel alongside Greens MP David Shoebridge and NSW Corrective Services Commissioner Peter Severin. Next door, Courtroom 2 held various media personnel set to report the Coronial inquest and the Dungay family’s supporters.


A mandatory inquest into the findings of David Dungay Jr’s death was held as David was in lawful custody at the time of his death. The NSW Coroner’s Court stated that the purpose of this inquest was not to penalise or punish any individual but rather to reflect and seek opportunities for improvement.


During the two hour inquest, the cause and manner of David’s death was discussed in detail and several recommendations were made. A major recommendation to highlight is alternative methods to the negotiation progress. Specifically, seeking the involvement of an Aboriginal inmate delegate or welfare officer within Long Bay hospital for Aboriginal or Torres Strait Islander inmates where required to reduce any likely use of force and consequent risk of injury.


Nonetheless, the submissions made by David’s family that the officers involved in David’s death should be charged were refused. The reason for this refusal according to the coroner, comes from the fact the officer’s evidence was given willingly in exchange for protection from self-incrimination. As such, officers were provided with certificates to protect themselves from being charged an indictable offence, which would mean any criminal charges to follow would be unfair. Coroner Derek Lee also noted that it was unlikely that the officers’ behaviours were motivated by “malicious intent,” but rather “a product of confusion annd misunderstood information.”


Families and supporters exited the courtroom in disbelief and enraged, demanding justice for David Dungay Jr. David’s nephew, Paul Silva, cried for his uncle’s death to not be swept under the rug since Aboriginal deaths in custody will only continue until someone is held responsible and the system changes. 


Commissioner Peter Severin was confronted in his car as he was about the leave by Dungay’s family members along with allies who demanded to know “how can you sleep at night when one of your staff killed our family member?” and chanted “justice today for David Dungay.”


“When you close your eyes I hope you remember this face, because me and my family do,” said Mr Silva.


Although the coronial inquest has concluded, this is only the first step toward justice for David Dungay Jr and other black deaths in custody which Justice Action continues to support. As David’s mother, Leetona said “I’m going to fight until I live in a country where black lives matter.”




Next Moves
The lawyers of the National Justice Project said they would continue to fight for David Dungay’s right to justice. There are three ways to take it on, all of which could happen at the same time.


1. Wrongful death
The right to sue members of the IAT and CSNSW for wrongful death exists when a person dies due to the legal fault of another person. In this case, if David had been left in his cell, and there was no cell move, he would be alive today.Wrongful death lawsuits sometimes come after a criminal trial, using similar evidence, but are held to the lower standard of proof of the balance of probabilities. In the celebrated case of OJ Simpson in the US, he was found not guilty of murder but successfully sued by his wife’s family. To successfully bring a wrongful cause of death action the Dungay family will need to prove the death of their son was caused by negligence by the guards or medical staff involved.


2. Director of Public Prosecutions DPP
Under the Director of Public Prosecutions Act 1990, the function of the Office of the Director of Public Prosecutions (DPP) is to conduct prosecutions. The lawyers on behalf of the family could ask that the DPP consider prosecuting the prison officers.


3. SafeWork NSW
The lawyers on behalf of the family could ask that SafeWork NSW to review evidence from this inquest and consider proceeding with a prosecution of Corrective Services NSW and/or its officers under the Work Health and Safety Act 2010.


Report on Inquest Last Day 8 March 2019

NSW Coronial Inquest into David Dungay      
Day Five (last day)   08/03/19

Key Points:

-       Problems in Corrective Services NSW, for responsible officer was unable to demonstrate ‘best practice’ in training and operations regarding de-esculation, and the safe management of inmates. The officer failed to locate in the NSW current manual a prior Queensland Coroner’s recommendations that no prone restraint be conducted on prisoners. There did not appear to be substantial progress in relation to some/all working guards obtaining specific training that was related to issues pertaining to Dungay’s death.

Poor progress was apparent regarding the training and delivery via an Operations Update on Corrective Services training of working staff on certain relevant issues: de-esculation not being an in practice priority; use of alternative equipment to riot helmets (to protect guards from spit); the failure to include Queensland Coronial Inquiry recommendations that relate to Dungay’s circumstances of death (but over a year prior to his death), advising that prone restraint technique NOT be used at all; the delivery of alternatives to prone restraint or of the risks of prone asphyxia to some/all staff, especially in Long Bay IAT; the use of ‘knee-ride’ pressure to an inmate’s back (that compresses the upper back) by officers/IAT.

-       The discussion and Coroner’s decision to not rescind a ‘Non-publication Order’ for the release to the public of the video that showed the failures of resuscitation that occurred after Dungay became ‘non-responsive’. This was despite requests by the Leetona Dungay Family and The Guardian newspaper, and options like the pixilation of faces.

-       During the court proceedings the Coroner provided time for each of the parent’s of David Dungay’s family to make separate ‘Family Statement’s.

-       Coroner Lee notified of the Time Frames for Submissions, and adjourned for the findings to be delivered at Lidcombe Coroner’s Court on 9am, 23 August, 2019

-       The inquiry ended with crowded public attendance in the public gallery, and with several major media present.

-       Post this inquiry, there was an emotional delivery to the media outside the court’s foyer of the Leetona Dungay Family’s ‘Family Statement’ (delivered directly by Leetona and her niece), and of the Hill Family (delivered on behalf of the family) ‘Family Statement’.

Below is a summary of the evidence given by witnesses, orders, family statements, and Inquiry submission & delivery of findings timetable.


Witness Statement 1 – ‘Officer U’ representing the Corrective Services Officers, IAT (Immediate Action Team) :

Dungay family’s lawyer, Mr Duncan Fire cross-examined Officer U about the Working Committee that was formed between Justice Health and Corrective Services in response to the issues of the Coronial Inquiry’s first two weeks of the Dungay case, raised post July 2018. (It was noted that Shaun Baggley is a member of the Working Committee - not cross-examined to date). The morning session focussed on the IAT obligation with ill persons to undertake a de-escalation strategies, to train ‘best practice’ including safety of staff and inmates, and regarding inmate safety the need and urgency in which alternatives like prone restraint practices are trained and implemented operationally.

Officer U was questioned as to whether the IAT recognised an obligation with mentally ill persons to undertake a de-escalation strategy, and, if there should be investigations into alternatives to prone restraint?   He answered that officers are trained to use the most effective restraints for staff, not to avoid prone restraint. There is a training package regarding the dangers of certain restraints, but not all staff are required to take this as a pre-requisite to work at IAT.

Mr Fire stated that Corrective Services’ ‘best practice’ should include the Queensland Coroner Court Mr Baggley’s recommendations that came out of the earlier death of Vaggs, which stated that prone restraints was not to be used in any situation by Corrective Services Officers. He asked Officer U if he could locate Baggley’s advice - that was to not use prone restraint - within the IAT officer section of the operations manual, and he replied ‘No, I cannot’. Officer U said the IAT & Corrective Services Officers were not trained to ‘not avoid prone restraint’, and it was ‘common in IAT to be used with enforced medication, but not so much outside of the Long Bay area’.

Asphyxia training is offered pre-placement in IOT officer role and during via online work yet is not required to start work. Training packages on asphyxia address statements like “ I cant breathe" as viewed as valid complaints of duress. One of the IAT Officers had used such knee pressure on Dungay’s back, but this was not taught within the training package.

Officer U’s reply regarding the operational use of prone restraint was that the IAT used to ‘not avoid prone restraint’, and it was ‘common’ in IAT’s to use enforced medication, but not outside the Long Bay area. Mr Fire questioned what alternatives existed to the use of riot helmets the IAT used, including whether face-masks were a viable option.   On the issue of equipment available to guards, for example, to stop being spat on, Officer U stated that officers especially in the IAT, while they used (riot) helmets, did have access to alternate equipment to protect staff’s face and eyes them such as gas masks   Asked, had anything changed since the Queensland Coroner’s Baggley Report, Officer U stated ‘No, not additionally’.

Regarding developing in future restraint alternatives for security operations, Officer U indicated that ‘eventually’ the number of restraints taught will change, but that the ‘IAT training package was not specific to prone restraint but to positional asphyxia’. It was acknowledged that any inmate reference to inability to breathe is recognised as a valid complaint of duress in asphyxia training. Officer U stated that Stage Two training is when staff are made aware of the signs of positional asphyxia, and added that claims of difficulty breathing can be misinterpreted by Corrective Services guards as non-compliance by an inmate. Officer U stated that every 2 years, online completion of training on positional asphyxia is to be done by IAT staff, and added, ‘Yes, a person could be rostered on without positional asphyxia training’. Officer U acknowledged that he had not had the training.

In relation to any proposal of increasing awareness on prone restraint, Officer U anticipated that ‘within the next 3 months training will be underway regarding prone asphyxia.   [Note: It is apparent that the formation of the Working Committee was not post Dungay’s death in 2015, but followed his Coronial Inquiry in July 2018, and that although Dungay died in 2015, and despite the working group, no additional operational changes have as yet been implemented.]

When asked about the IAT training package 2 in relation to the dangers of placing a knee on the back – ‘knee ride’, to which the C U referred to the large turnover of IAT staff.


Application to the Coroner to rescind a ‘Non-publication order’

On behalf of the Leetona Dungay family, Mr Fire sought for Coroner Lee to rescind the non-publication order for the video footage post Dungay’s non-responsive period. Extensive discussion about the capacity to change the order, the potential for public interest in showing the video, and particularly, that Mr Hill had conveyed to the Counsel to the Coroner that he was not wanting his part of the family to see this footage.

Questions referred to how this video may be in the public interest or to serve justice, and if anything had changed since the order was made that may influence the decision to change this order.   The inquiry is about material becoming open to the public, and an order for non-publication exists for exceptional circumstances, such as that which would render justice impracticable or not serve in the public interest.

Mr Windsor on behalf of Corrective Services listed 6 points about such orders: beginning with the necessity for open justice; including the interest of the Hill family; and concluded with Justice Johnson case where the deceased deserves ‘dignity and respect, even in death’. Family members and others in the public gallery reacted to this statement, and a family member responded “How dare you!” and left the court room, while others responded to him, “hear hear”

Mr Dawson, the representative for the medical doctors proposed an alternative to address concerns: that all faces including Dungay be pixilated.  

Mr Fire’s arguments to allow publication of the whole video were: it is important evidence; whilst it is distressing, the Hill family can take steps can be taken to avoid seeing it; and it would serve the public interest.

The Counsel for the Coroner argument included that there was ‘no basis’ and concerns that it would broaden the base of public interest concerns. After asking ‘What had changed since the order was made?’, Coroner Lee refused to rescind of the order, under Section 74 (1).

Family statements presented to Court:

Ms Leetona Dungay who has been leading the legal actions to investigate the death of her son - David Dungay - and attending all of the Coroner’s Inquiry, introduced herself and thanked the Coroner for allowing her to speak in court. With family members around her, and at times teary, she read from a prewritten script[1] that offered personal, family remembrances: of how David made it to Year 10 certificate and got a job after leaving school, how he managed his diabetes, and that he was enjoyable family member. Cynthia read a poem about her deceased brother, as did his nephew who read a poem David had written while in jail about how he was languishing in prison.

Counsel read the statements from Dungay’s father, Mr. Hill, and one of David’s brothers, Jack

The Coroner banned news media from recording family statements.

Time frame for submissions (before 5pm) was announced by Coroner Lee as:

17 May              Counsel Assisting the Coroner

7 June                Mr Fire, Dungay Family lawyer

21 June             Other submissions

5 July                 Responses by Counsel Assisting the Coroner

The case was adjourned, with findings to be delivered at Lidcombe Coroner’s Court:

Friday 23 August, 2019 9am

Post Court Family Statement read to the Media:

Leetona Dungay script presented to Coroner Lee and after court, to the media: 

Following the closure of court proceedings Leetona Family gave a media presentation of their Family Statement they had earlier presented in court time, read out be a family member while outside of the foyer of the court.

The lawyer for Hill family read out a letter written by father and son of David Dungay.

[1] Leetona Dungay script presented to Coroner Lee and after court, to the media: Https://m.facebook.com/story.php?story_fbid=783468022030582&id=100011021732369



Death of Miriam Merten

Deaths In Custody

Lismore Base Hospital horror: Why was mum Miriam Merten left to die? |  Daily Telegraph

(Miriam left to wander naked in the corridors: The Daily Telegraph)

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Justice Action submitted a report to the NSW Health Department Inquiry after the death of Miriam Merten, mother of two and a mental health patient from Lismore Base Hospital. Miriam died on 3rd June 2014 from injuries sustained during her time in seclusion. The horrific nature of Miriam’s treatment was evidenced with shocking CCTV footage of her final hours, exposing the lack of care from the NSW Health Staff at Lismore Base Hospital along with their abject failure to intervene in her untimely death.

Ms Merten died in 2014 from a brain injury after she fell more than 20 times whilst in the care of the Mental Health Unit of Lismore Base Hospital. The coronial inquest into Ms Merten’s death found that Ms Merton died from a "traumatic brain injury caused by numerous falls and the self-beating of her head on various surfaces, the latter not done with the intention of taking her life". Disturbing CCTV footage of the neglected, blood and faeces splattered, Ms Merten wondering the corridors of the Lismore facility on the night of her death have emerged, and be viewed in this article.





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