Inquest slams nurse’s ‘inadequate’ care of Indigenous man
A coroner has ruled a young Indigenous man did take his own life in a NSW prison but has referred a senior nurse who assessed him an hour before he was found to a professional standards board.
Tane Chatfield, 22, was found unconscious in his cell by a prison sweeper at Tamworth Correctional Centre on the morning of September 20, 2017.
Mr Chatfield, who grew up in the Armidale area and had been on remand at the facility for two years, had only just returned from Tamworth Base Hospital after suffering a series of seizures in his cell.
He died in hospital two days later, after what Deputy State Coroner Harriet Grahame ruled was suicide, despite his family's scepticism.
In findings handed down on Wednesday, Ms Grahame criticised the decision to place the father in a cell on his own when he returned from hospital.
She also recommended the correctional centre's Justice Health clinic nurse unit manager Janeen Adams be investigated by a professional body over her "cursory and inadequate" treatment of Mr Chatfield on his return to jail.
The inquest heard Ms Adams assessed her patient for a matter of minutes before allowing him to be returned to a cell on his own.
Ms Adams gave evidence that she did not know the man had suffered from seizures, and had not been provided with a hospital discharge summary.
Ms Grahame said in her findings the experienced Ms Adams could have called the hospital or simply "asked Tane himself".
"I have given this matter considerable thought … However, I am troubled that a nurse of her experience appeared to consider the interaction she had with her patient to be sufficient in the circumstances," Ms Grahame wrote.
"While she stated that had she known of the seizures she may have taken a different course, she did not appear to understand that she should have known."
Justice Health has previously acknowledged Mr Chatfield did not receive the required care before his death.
As part of her recommendations Ms Grahame said Corrective Services NSW should conduct an audit of the Tamworth jail.
Any inmate taken to hospital should be placed in a two-person cell when they return, she recommended in her findings.
Ms Grahame said the story of Mr Chatfield, first incarcerated at 14, was one that highlighted the need to divert "over-represented" young Indigenous people away from jail in order to prevent deaths in custody.
"I am so sorry that Tane experienced such despair in circumstances which were unsafe for him," she said.
Originally published as Inquest slams nurse's 'inadequate' care