Inquest into the death of Tane Chatfield

Contributing factors

• inadequate clinical assessment on return from hospital
• failure to obtain discharge summary before cell placement decision
• failure to recommend two-out cell placement despite recent seizure and known self-harm history
• separation from cellmate causing significant distress
• placement in cell with obvious hanging point
• apparent substance use disorder and drug withdrawal
• post-ictal state potentially contributing to suicidal ideation
• lack of sustained psychological care or Aboriginal health support in custody
• interpersonal stressors including separation from family and relationship concerns
• isolation in locked cell without supervision

Coroner's recommendations

1. CSNSW conduct a comprehensive audit of all cell hanging points at Tamworth Correctional Centre and undertake urgent removal of any hanging points identified.
2. CSNSW amend policy to notify the next of kin if an inmate is taken to hospital in a medical emergency, even if not ultimately admitted.
3. CSNSW implement a policy whereby prisoners who have been taken to hospital are not returned to prison without a discharge summary.
4. CSNSW and Justice Health adopt a policy whereby any inmate who has been taken to hospital is placed either two out or in an assessment cell until a comprehensive Justice Health review can take place, with any other placement documented with reasons recorded.
5. CSNSW and Justice Health actively recruit Aboriginal health workers at Tamworth Correctional Centre, including consideration of expanded culturally appropriate Drug and Alcohol and Mental Health Services and workers with expertise in suicide prevention strategies.
6. Hunter New England Local Health District provide a copy of discharge summary to officer escort when a custodial patient is discharged from a HNE health service including Emergency Department.
7. Transcript of evidence of Ms Adams be forwarded to Chief Executive of Nursing and Midwifery Board of Australia for consideration of professional conduct review.