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Tane Chatfield Coroner’s Inquest - NSW Coroner’s Court - 16/7/20

The court heard evidence from expert witnesses, neurosurgeon - Dr. Neil Simon, forensic pathologist - Dr. Stephen Cordner, psychiatrist - Dr. Matthew Large, and Corrective Services employee Saffron Cartwright. 

 

Dr. Neil Simon’s testimony consisted of a medical analysis into Mr. Chatfield’s seizure and the appropriateness and reasonableness of the care and action taken towards Mr. Chatfield in the events leading towards his death. During the testimony the doctor discussed the findings of a pineal and basal cyst and their potential inducement of the seizure Tane experienced. He stated that, in his belief, the cysts were not highly relevant or of functional significance to Tane’s seizures as the identification of cysts in an individual is not a factor in diagnosing epilepsy. He also stated that the autopsy findings did not indicate that Tane had a neurological disorder, as a neurologically-based autopsy would most likely lead to incidental findings which may or may not be relevant. He did mention however that there remains a limited understanding surrounding seizure genesis within the medical field and thus no possibility was able to be comprehensively ruled out. 

 

Following this there was considerable discussion on the potential experience of a postictal period. The postictal period may have contributed to suicidal behaviour, as it has been found that individuals may experience a disturbed thought process following a seizure. The postictal period, however, is not a set timeline and varies for individuals. The doctor stated that the period of time Tane was kept in the hospital was the standard observation time of 8 hours, which covered the period any postictal symptoms or the manifestation of a psychiatric illness would have emerged. If none were observed within that time they would be deemed fit to be sent home as a delayed event of such nature would not be expected to occur. He also stated that postictal symptoms were not observed in Tane based on the audio-deficient CCTV footage he viewed, yet in the absence of postictal psychosis there remains a chance for suicidal behaviour. 

 

Questioning resulted in the finding that despite the risk of increased suicidality following seizures, supervision within NSW goals is only recommended to those that present with elevated psychiatric symptoms. There was also brief mention on whether discharge of the patient based on suicidality following a seizure would differ if the patient was living at home with others or living at home by themselves (being alone presents a higher risk), or in custody and isolated from others, as this would be comparable to being alone and therefore lead to the patient being at a higher-risk for suicidal behaviour. 

 

The use of an electroencephalography (EEG), which monitors electrical activity within the brain, arose many times during the testimony as a method to determine whether Tane was suffering from epilepsy. Dr. Simon’s view was that Mr. Chatfield’s seizure was not one of an epileptic nature and was likely a psychogenic drug withdrawal related seizure, despite the fact that Tane had previously suffered from seizures following discussion on the various inducements of seizures. He also acknowledged that the conclusion arrived at by the medical team on the day seemed reasonable given the information they had access to: although a different conclusion may have been reached had they had all the information that he was given following the events of Mr. Chatfield’s death. 

 

Subsequently there was some mention of withdrawal from the drugs buprenorphine and mirtazapine and resulting psychosis of withdrawal, however, Dr. Simon specified that this was not within his expertise and was consequently unable to discuss the matter. 

 

The notification to health personnel of previous self-harm was considered in relation to the existence of approximately 15 parallel scars ranging from 30-40 millimetres on Mr Chatfield’s left forearm with the longest closest to the wrist. Dr. Simon responded that it would have been an indicator of self-harm, however, that it was not right to assume that the forearm scars were automatically contributory to epileptic seizures. 

 

Some questions regarding the appropriateness, from a medical view, of policy and procedural actions that had taken place during the events of Tane’s death and medical ordeal beforehand arose during the testimony. Dr. Simon refused to answer as he considered these outside his expertise. 

 

Dr. Stephen Cordner took the stand next with a short testimony mostly consisting of agreeing with the reports and findings of Tane Chatfield’s death. He stated that, despite viewing the 38 sensitive pictures taken by the family of Mr Chatfield while he was in the Intensive Care Unit, his opinion that Mr. Chatfield died as a result of hanging and that there was no foul play leading to his death.

 

Dr. Michael Large was the third expert for the day, a psychiatrist who worked in the Prince of Wales Hospital. He stated from his report that he felt that the best way to reduce deaths in custody is to reduce rates of Indigenous incarceration. He was of the opinion that Tane did not suffer from a high-impact mental disorder at the time of his death, and said that it was likely Tane had a non-epyleptic seizure. However, he did state that Tane did have a substance use disorder as a polysubstance user, and that the opiate withdrawal Tane was experiencing would have been subtle to others, but had dysphoric effects on Tane. Dr. Large also noted various suicide risk-factors for Tane, such as gender, Drug withdrawal and history of suicidality, but noted that such factors were not predictive. 

 

A further set of questions led to Dr. Large stating that suicide is often an impulsive decision, and that death by suicide is not that well-linked to suicidal ideation, despite commonly held beliefs. Dr. Large also stated that Tane felt “quite alone”, and that the prison should have provided more therapy or staff engagement. Finally, he also emphasised the importance of removing hanging points in custodial settings as a crucial intervention that will save lives, stating that it should be a “universal precaution”. 

 

The final witness was from Corrective Services NSW (CSNSW) - Ms. Saffron Cartright. Initially, Cartright was reluctant to acknowledge that CSNSW would benefit from having more Aboriginal staff members, constantly trying to frame her answers around discussing existing programs and the dedicated staff that they have in place for Aboriginal people, like the Aboriginal Regional Corrections Officer, although many of these were spread across the region, not directly in prisons. The question itself put forward by the Coroner’s Assistant was instead directed more towards allowing more support systems for Aboriginal people within prisons, rather than what was already in place.

 

Justice Grahame seemed to be in disbelief that there had not been an audit of Tamworth Correctional Centre following Mr. Chatfield’s death, and that the hanging points were yet to be removed. The only memo on deaths in custody had occurred in 2010, and led to some facilities in certain regions implementing some of the suggested strategies. Similarly, since Tane’s death, only the cells with the exact same pipe had them covered, and two grills were removed, with no more comprehensive action taken. There had been 4 deaths in custody in Tamworth Correctional Centre since the 1980s. Cartwright did note that since Tane’s passing, CSNSW had set up an Aboriginal Steering Committee that helped organise more programs to help Indigenous inmates. Finally, Ms. Cartright found it difficult to answer as to why CSNSW had struggled to fill positions for those of Aboriginal heritage, denying it was tied to poor work culture or efforts.

 

The day focused primarily on expert witnesses discussing Tane’s seizure and the medical processes surrounding it, while also briefly examining a CSNSW Officer, focusing on policy and procedural questions.

 

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