Inquest into the death of Mati Tamwoy

Contributing factors

• plasmablastic myeloma transformation from multiple myeloma
• aggressive chemotherapy in context of pre-existing ischemic heart disease
• immunosuppression from chemotherapy and cancer
• inappropriate application of restraints affecting emotional wellbeing
• confusion between Directives and SOPs regarding restraint policy

Coroner's recommendations

1. NT Department of Corrections should conduct thorough review of all Directives and Standard Operating Procedures concerning use of restraints on prisoners under medical escort and prisoner in-patients to ensure consistency and clarity, and to ensure correctional officer discretions are appropriate to their training and role. All correctional officers should receive training on new or updated Directives and SOPs.
2. Directives and Standard Operating Procedures referable to maintenance of Hospital Journal or Hospital Bedsit Log should be reviewed and consolidated into one Directive or SOP. The procedure should include requirement that application of restraints be clearly identified in the journal/log. All correctional officers should receive training on the consolidated Directive or SOP.
3. Relevant Directives and Standard Operating Procedures should be reviewed to ensure that up-to-date next of kin and/or emergency contact details are accurately recorded, and alternatively, that it is clearly recorded that a prisoner declines to provide such details and/or declines to consent to persons being contacted.