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.

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