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

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. 

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.

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

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