Warning: This story contains images of an Indigenous person who has died.
The NSW Coroner is calling for change at Tamworth Correctional Facility after an inquiry into the death in custody of Aboriginal man Tane Chatfield in 2017.
Mr Chatfield died in Tamworth Hospital on September 22, 2017, after being found unconscious in his cell at Tamworth Correctional Facility one day before he was presumed to be released.
NSW Deputy Coroner Harriet Grahame who presided over the inquiry into Mr Chatfield's death said he received inadequate care from Justice Health and found evidence given by the treating nurse to be 'implausible'.
The inquest ruled Mr Chatfield's death in custody was "self-inflicted" however his family and supporters do not accept this finding.
Outside Armidale Courthouse Nioka Chatfield, the 22-year-olds mother said she believed he didn't make it because of the colour of his skin, according to a report by the ABC.
Deputy Coroner Harriet Grahame handed down seven recommendations addressed to Corrective Services, Justice Health and Hunter New England Local Health District.
The first recommendation urged Corrective Services to conduct a full audit of cell hanging points at Tamworth Correctional Facility and "undertake urgent removal".
Other recommendations for Corrective Services include notifying next of kin when an inmate is taken to hospital and implementing a mandatory discharge summary for all prisoners who have been taken to hospital before they return to prison.
In a statement, Corrective Services said they are reviewing the Coroner's findings and will look at amending policies in line with the recommendations.
"Remediation work has since been undertaken at Tamworth Correctional Centre to remove similar hanging points," said Corrective Services in a statement.
During the inquest, the prison's Manager of Security gave evidence that the facility is old and limited changes can be made to the infrastructure also stating the organisation must prioritise funding.
Deputy Coroner Grahame said this response is entirely inadequate and recommended further formal audits be conducted.
Further recommendations urged Corrective Services and Justice Health to 'actively recruit' Aboriginal health workers at Tamworth Correctional Facility and inlcude culturally appropriate drug, alcohol and mental health services.
The coroner also noted the failure of the NSW justice system to reduce the grossly disproportionate incarceration of Indigenous people.
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Image - Wendy John