Inquest into the death of Mati Tamwoy

66y · Male·infectious complications of plasmablastic myeloma

Mati Tamwoy, a 66-year-old Aboriginal man, died in ICU from infectious complications of plasmablastic myeloma after 661 days on remand. He received excellent oncological care including chemotherapy and radiotherapy. However, the inquest identified significant systemic failures in correctional policy application: (1) he was inappropriately shackled to his hospital bed throughout multiple admissions despite having low security rating—policy required restraints only for high/medium security prisoners unless elevated risk justified it; (2) hospital journal maintenance was inadequate, creating uncertainty about restraint application and failing to document mandatory 60-minute checks; (3) no next of kin was notified following his death, contrary to directive requirements. While shackling did not contribute to his death, it was unnecessarily demeaning during terminal illness. The coroner emphasised confusion arose from contradictory SOPs conflicting with Directives, inadequate staff training, and correctional officers lacking medical expertise to assess medical discretion criteria.