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.

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