A senior prison nurse who provided "cursory and inadequate" care for an Indigenous inmate in the hour before he took his life in a NSW jail has been referred to a professional standards board.
But NSW coroner Harriet Grahame stressed deaths in custody of Aboriginal men like young father Tane Chatfield won't be reduced unless Australia properly grapples with the factors underlying the "grossly disproportionate" incarceration of Indigenous people.
Mr Chatfield, 22, died in hospital two days after he was found hanging in his cell at Tamworth Correctional Centre on September 20, 2017.
He'd only been back in the prison for an hour after spending the night in Tamworth Base Hospital following multiple seizures in his cell.
Ms Grahame on Wednesday ruled the death suicide but was critical of the prison system's care for the Kamilaroi Gumbaynggirr Wakka Wakka man.
Before being escorted back to his cell on return from hospital, Mr Chatfield was assessed for "only a matter of minutes" by senior nurse Janeen Adams.
The nurse had little understanding about why he'd gone to hospital.
"The failure to make inquiries about the reason for Tane's admission to hospital demonstrates a lack of clinical care and a failure to establish a rapport with the patient," the coroner said, in written findings.
Ms Adams gave evidence that the prison officer accompanying Mr Chatfield to hospital gave conflicting clinical information and made no mention of seizures.
No hospital discharge summary was available at the time.
While finding parts of the nurse's evidence "inherently implausible" the coroner wasn't in a position to definitively find that Ms Adams had knowledge of Mr Chatfield's seizures.
"However, it is clear that whether or not she actually knew, she should have known," Ms Grahame said, outlining various basic options available to the nurse.
"She could simply have asked Tane himself."
Ms Adams told the court she had "many, many years of experience" as an emergency department nurse.
"In my view, the care (Ms Adams) provided to Tane was cursory and inadequate," Ms Grahame said, before referring the matter to the Nursing and Midwifery Board of Australia.
Justice Health, the healthcare provider in NSW prisons, has previously acknowledged Mr Chatfield received inadequate care.
Ms Grahame was also critical of the decision to place Mr Chatfield in a cell on his own while awaiting the hospital discharge summary, and the fact that he was able to find a hanging point in that cell.
Among her seven recommendations, she pressed NSW prisons' boss to urgently audit and remove all hanging points in the Tamworth cells.
She also called for next of kin to be notified if an inmate was taken to a hospital in a medical emergency, even if that inmate was not ultimately admitted.
Ms Grahame also wants the active recruitment of Aboriginal health workers for the Tamworth prison, where more than half of prisoners are Indigenous.
While outside the bounds of her inquest, the coroner mentioned the failure of the NSW justice system to appropriately reduce the "grossly disproportionate incarceration of Indigenous people or to properly grapple with the underlying factors".
"Quite simply, more young Aboriginal men like Tane must be diverted away from the criminal justice system if we are to reduce the number of Aboriginal deaths in custody nationally," she said.
Mr Chatfield first entered custody aged 14 and had spent two years on remand.
His death is not the first impulsive Indigenous suicide Ms Grahame has been called to investigate this year.
"Tane's death must be understood in its context of real social injustice, ongoing dispossession and his lived experience of inter-generational trauma," she said.
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Australian Associated Press