Inquest into the death of Tammy Michelle Shipley

47y · Female·hyponatraemia arising from primary polydipsia and complications of schizoaffective disorder and its treatment

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.