It took nearly a week for white Australia to notice that Tane Chatfield had died.

The 22-year-old father of one was found unconscious in his cell at Tamworth Correctional Centre about 9am on Wednesday, September 20. He died in hospital two days later.

His death did not go entirely unnoticed. On the day he died, a Facebook post by his sister, Jody Pitt, was shared thousands of times. Nearly 100 people marched in protest outside Tamworth jail a day later, demanding “justice for Tane”. A GoFundMe campaign to raise money for his funeral collected more than $2000 in two days.

But it wasn’t until the Monday after he was found in his cell – a lapse of five days – that media outlets began reporting on yet another Aboriginal death in custody. Indigenous information portal Welcome to Country noted that the death of a giant crocodile in Queensland attracted more media attention over the weekend than the death of a black man in jail.

Speaking to The Saturday Paper, Pitt remembers her brother as an “active, outgoing” young man who enjoyed painting, was “a great dad” to his three-year-old son, and fiercely loved his family. “He worshipped the ground they walked on,” she says. “He had his troubles, like everybody else, but took it on the chin.”

Pitt says Tane, a North Queensland Cowboys fan who idolised injured captain Johnathan Thurston, was excited to watch his team score several upset victories in recent weeks to stay in the NRL finals series.

Her brother’s death has compelled Pitt to become politically active around black deaths in custody. “It’s never been my forte, but something like this happens and it makes you want to do it.”

While Corrective Services NSW has ruled Chatfield’s death non-suspicious, pending a coronial inquiry, Pitt and the rest of Chatfield’s family say he was happy at the prospect of being released. “I’ve known my brother for 22 years and he’s had a lot of problems in his life, but never once has he tried to take his own life for his problems,” Pitt says.

Chatfield’s death has exposed an inconvenient fact: Indigenous people are dying in NSW prisons far more often than the popular narrative suggests.

New South Wales is regarded as a relatively bright spot in Australia’s abysmal record of Indigenous deaths in custody, but Chatfield’s death has exposed an inconvenient fact: Indigenous people are dying in NSW prisons far more often than the popular narrative suggests.

NSW’s reputation as a leader in preventing Indigenous deaths in custody is largely thanks to its Custody Notification Service (CNS). The service was introduced in 2000, in accordance with recommendations handed down by the 1991 Royal Commission into Aboriginal Deaths in Custody. By law, NSW Police must notify the Aboriginal Legal Service whenever they detain an Indigenous person. A lawyer from this service will contact the person to inform them of their rights, provide legal advice, check their mental health, and ensure they are given any medication or medical care they need. The CNS then contacts the person’s family so they know where their loved one is, as well as an Aboriginal field officer if the person or their family need language or cultural translation to navigate the justice system.

The system NSW pioneered is not perfect. Rebecca Maher died in a Maitland police station holding cell in August 2016 after being detained out of “concerns for her welfare”. Police allege Maher was heavily intoxicated, but she was never charged and a report seen by Maher’s family indicated she had no alcohol or illegal drugs in her system when she died. The Aboriginal Legal Service furiously noted that police did not use the CNS to let them know Maher was in their custody, and failed to inform them of Maher’s death for 24 days.

Maher made headlines partly because her death was so unexpected. The CNS’s success in preventing Indigenous deaths in police custody over 17 years is indisputable. The service reaches an average of 350 detained Indigenous people in NSW and the ACT every week. It’s no coincidence that NSW and the ACT, the only jurisdictions to have a mandatory service such as this, have had vastly lower rates of deaths in police custody than anywhere else.

The need for such services nationwide was underlined in 2014, when 22-year-old Yamatji woman Ms Dhu died of septicaemia and pneumonia in her cell at South Hedland police station. The case put Australia’s lack of a consistent national standard for custody notification in the spotlight, and generated enough political pressure for the federal government to issue a standing offer to fund any new state or territory notification service for three years. Thanks in large part to campaigning by Dhu’s family, the new West Australian Labor government has indicated it will consider introducing a mandatory CNS. South Australia, which has had four Indigenous deaths in custody in the past year, is also reportedly “considering” taking up the government’s offer.

But Australia’s focus on custody notification has masked other serious failings within the NSW justice system. The term “deaths in custody” commonly refers to deaths in police station holding cells. The chief legal officer of the Aboriginal Legal Service NSW/ACT, Nadine Miles, notes that the “classic” definition of police custody ignores the complexities of the issue.

“For the purposes of investigation by the Coroner’s Court of NSW, ‘police custody’ applies when someone is being arrested or investigated or chased in a car, for example,” Miles says. “Then there’s corrective services custody, there’s custody in an institution like a secure hospital ward.”

While the NSW notification service has successfully curbed Indigenous deaths in the hours and days after someone is picked up by police, that safety net falls away if they are sent to prison. Maher’s death in police custody was NSW’s first in 16 years, but Corrective Services NSW has recorded 106 deaths in its custody since July 2012, 13 of which were Indigenous men.

In July, 35-year-old Kamilaroi man Eric James Whittaker died from head injuries sustained in Sydney’s Parklea Correctional Centre. Whittaker’s family said Corrective Services NSW and police had offered them conflicting explanations for his injuries, and that he was shackled to his hospital bed for the last two days of his life, despite being in a coma.

In December 2015, 26-year-old David Dungay Hill died in the mental health unit of Sydney’s Long Bay Correctional Complex after being restrained and sedated by prison guards. Hill, who suffered from chronic paranoid schizophrenia and diabetes, was pinned to the ground twice after refusing to stop eating Tim Tams in his cell. CCTV footage of Hill’s death recorded him repeatedly telling guards he couldn’t breathe, and guards replying, “If you can talk, you can breathe.” Hill and Whittaker were cousins.

David Wotherspoon died in April 2013 after being found unconscious in his cell in Cessnock Correctional Centre. He was 31. A NSW Coroner’s report released in August found that “David’s mental health deteriorated without sufficiently prompt and active intervention”, and that his request to be transferred to a specialist mental health facility was delayed “for reasons that were not adequately explained”. The coroner also found the prison officer tasked with overseeing CCTV footage of inmates’ cells was overworked and inadequately trained, contributing to her failure to notice Wotherspoon covering the lens of his cell camera 20 minutes before he was found.

Most of these deaths appear to have breached recommendations of the 1991 royal commission. It found that “it is undesirable in the highest degree that an Aboriginal prisoner should be placed in segregation or isolated detention”, and that “wherever possible an Aboriginal detainee should be accommodated with another Aboriginal person”. Both Chatfield and Wotherspoon were in cells by themselves. It also found that “police and prison officers should receive regular training in restraint techniques” that “positively discourage the use of physical restraint methods except in circumstances where the use of force is unavoidable”.

This is not just a NSW problem. A day before Chatfield’s death, another Indigenous man died after an altercation with an inmate in Queensland’s Townsville Correctional Centre. Last week, the family of Wayne “Fella” Morrison marked one year since he was killed in a violent confrontation with prison guards in Adelaide’s Yatala Labour Prison.

But the extent to which the success of the custody referral service has overshadowed NSW’s broader failings is alarming. A justice system that can only keep people safe in one kind of custody is not working.

Tane’s family has been flooded with messages of support, including from the families of other Indigenous people who have died in custody. The NSW Koori Knockout, an all-Indigenous rugby league tournament in Sydney and one of the largest Indigenous gatherings in the country, has publicised Chatfield’s death in solidarity.

Tane’s family has given media outlets permission to use his name and images, and are insistent that his death not be another example of Australia’s historic indifference to black deaths. “The reason we’ve been doing social media so much is partly because it’s so fresh, but also because we don’t want him to be forgotten about so quickly and easily, like so many people are,” his sister says. “That’s where we’re trying to make a difference.”

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