A correctional centre nurse has admitted if more information was available she would not have directed a young Indigenous man who died in NSW custody to spend his final moments alone in a cell.
Tane Chatfield, a 22-year-old father, died in hospital on September 22, 2017 after being found hanging in his cell at Tamworth Correctional Centre by officers two days earlier.
The Kamilaroi Gumbaynggirr Wakka Wakka man had been held on remand for two years and was taken to Tamworth Base Hospital on September 19, where he stayed overnight, after suffering from multiple seizures.
During questioning at an inquest into Mr Chatfield's death on Tuesday, it was revealed he should have been sent to a two-person cell after returning from hospital.
Janeen Adams, a nurse unit manager who Mr Chatfield presented to after returning to the prison from hospital about 8am on September 20, told the inquest she did not have the required documents to "clinically indicate" the man would require company.
The inquest, headed by deputy state coroner Harriet Grahame, heard Ms Adams was waiting for a discharge summary from the hospital as well as an overnight report.
Ms Adams said she had no knowledge of Mr Chatfield's seizures the night before and that he appeared "alert and calm", "answered appropriately to questions" and told her he was feeling OK.
She directed him to rest alone in a cell until it was possible to have him back at the clinic for review.
But when asked by a lawyer at the NSW Coroner's Court if it would have been "prudent" to place Mr Chatfield in a cell with another inmate while waiting for the reports, Ms Adams said: "In hindsight, yes."
"But I made that decision based on the presentation of the patient and information before me," Ms Adams told the inquest via AVL.
"The patient had been medically cleared back to the community setting."
Earlier on Tuesday, the inquest heard Mr Chatfield was in "10 out of 10 pain" after suffering multiple seizures on his last night in remand.
On three separate occasions he requested and received Panadol and Endone after being taken to Tamworth Base Hospital on September 19, according to officers who guarded him overnight.
Correctional officer Harrison Fittler on Tuesday told the inquest Mr Chatfield "curled himself into a ball" and complained of body aches sometime between 1.30am and 2am on September 20.
He also recalled speaking to Mr Chatfield about his family, his hope for acquittal in court and how he was looking forward to spending time with his partner and son.
Mr Fittler said Mr Chatfield was unhappy about being discharged from hospital after daybreak due to lingering pain but appeared "calm and relaxed" upon his return to prison.
"From what I could see he wasn't disoriented or showing any signs of concern," Mr Fittler said.
The inquest on Monday heard Mr Chatfield on September 19 had expressed distress at his separation from cellmate Darren Brian Cutmore, who claims to have played an "older brother" role to the younger man.
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Australian Associated Press
