Inquest into the death of Tammy Michelle Shipley
Deceased
Tammy Michelle Shipley
Demographics
47y, female
Date of death
2022-12-20
Finding date
2025-01-16
Cause of death
hyponatraemia arising from primary polydipsia and complications of schizoaffective disorder and its treatment
AI-generated summary
Tammy Michelle Shipley, a 47-year-old Aboriginal woman with chronic schizoaffective disorder and bipolar disorder, died in custody on 20 December 2022 from hyponatraemia arising from primary polydipsia. She was arrested on 9 December 2022 for minor shoplifting offences. Critical failures included: NSW Police failed to record her documented mental health history in custody records despite having multiple recent interactions with her showing mental illness; the NSWPF Facts Sheet falsely stated 'Police not aware of any drug or mental health issues'; the police prosecutor failed to inform the Magistrate of her mental health history during bail hearings on 10 and 14 December; and the prosecutor failed to clarify that Ms Shipley did not retain bail on one shoplifting charge, causing the Magistrate to believe he was releasing her when he actually was not. These systemic failures meant Ms Shipley received no mental health assessment or diversion to mental health services despite clear indicators. Expert evidence confirmed she was in an acute psychotic phase at arrest, could not have received adequate treatment in custody, and would have been better served in community care. The inquest reveals failures in police mental health response protocols, information sharing between agencies, and courthouse procedures for unrepresented mentally ill defendants.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Acute phase schizoaffective disorder and bipolar disorder at time of arrest
- Failure of NSW Police to record known mental health history in custody management record
- False statement in NSWPF Facts Sheet stating police unaware of mental health issues
- Lack of mental health assessment during police custody despite indicators of acute mental illness
- Failure to utilize PACER team or Mental Health Act s.22 assessment options
- Lack of information sharing between NSW Police and subsequent decision-makers
- Police prosecutor failure to inform magistrate of Ms Shipley's mental health condition
- Prosecutor failure to clarify bail status on H76115633 charges at 14 December court appearance
- Magistrate believed he was releasing Ms Shipley when she actually remained in custody on other charges
- Absence of legal representation for unrepresented defendant at bail hearings
- Inadequate mental health treatment available in Mum Shirl Unit at Silverwater Women's Correctional Centre
- 10 days between arrest and death without adequate mental health intervention
- Custodial environment unsuitable for mental health crisis management
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —