Warning:Aboriginal and Torres Strait Islander readers are advised that this article contains images and names ofIndigenous Australianswho have died. This story contains descriptions of self-harm and some readers might find it distressing.
In a small rural cemetery in Armidale, a young boy sits by a grave, gazing up at a portrait embedded in the black marble headstone.
The boy is quiet. He’s taking in the face of the young man before him.
Tane Chatfield, the inscription reads. A loving father. A beloved son.
When the boy gets home, he asks his grandmother, Nioka Chatfield, a question.
“He doesn’t say the word die – he calls it ‘bombed’,” Nioka says. “So he says, ‘Nan, how did my dad get bombed?’”
Nioka doesn’t know what to say.
There’s so much to tell. But her grandson is only 11.
Tane, a proud Gamilaraay, Gumbaynggirr and Wakka Wakka man, died by hanging in Tamworth correctional centre in 2017. He had been on remand for two years, awaiting trial, and was innocent in the eyes of the law.
When Tane entered custody he was clearly identifiable as a prisoner at risk. Yet he was provided no sustained psychological support or drug and alcohol treatment.
He was also placed into a cell that had an obvious hanging point. A coroner later described that point as a “lethal method immediately and obviously available” to Tane.
It should not have been there. More than 30 years ago, like all state governments,New South Walesagreed to remove hanging points from its jails in response to the 1991 royal commission into Aboriginal deaths in custody.
When asked by the coroner to explain the failure, a senior NSW corrections officer blamed the jail’s “heritage” listing, saying this restricted physical changes to the building. She claimed that the complex had been built in the 1700s – before European settlement of the area.
Guardian Australia has spent months investigating hanging deaths like Tane’s in every state and territory. The investigation hasrevealed a staggering death toll linked to inactionon known hanging points.
Across 19 prisons, at least 57 hangings occurred using ligature points that were known to authorities but not removed. In one case thesame point was used in 10 hanging deaths, despite repeated, early warnings that it be immediately removed.
Official data shows the rate of Aboriginal hanging deaths is at a 17-year high. Seven Indigenous Australians hanged themselves in prison in 2023-24, according to the latest data available, a record not seen since 2000-01. It correlates with Australia’s surging prisoner population.
Indigenous Australians remain vastly overrepresented in prison populations andhundreds have diedin custody – 101 of those by hanging – since the 1991 royal commission.
Australia’s longest serving Indigenous affairs minister, Robert Tickner, who presented the royal commission’s report to federal parliament and helped secure agreement to its recommendations, is outraged. “There can be no excuses for the failure to act,” he says.
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“We must not as a nation take our focus off the core recommendation of the royal commission, which was reducing the numbers of Aboriginal people in the criminal justice system.
“I’ve just come from a parliamentary committee in NSW and they’ve asked me, have things changed in all those years? And, very sadly, in this space, no. The numbers are still truly shocking.”
The coroner who investigated Tane’s death, Harriet Grahame, said authorities had failed to tackle the “grossly disproportionate incarceration of Indigenous people” in the three decades since the royal commission.
Governments, she said, had also failed to address the underlying factors driving overrepresentation, including glaring disadvantages across economic, health, housing and education spheres.
“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.
The failures did not stop after Tane’s death.
In 2020 the NSW coroner told the state government to audit Tamworth prison for obvious hanging points and to have them removed.
The audit was conducted in October 2020. The government reported back that it “did not identify any obvious cell hanging points”.
Guardian Australia can reveal that, within 12 months of that audit, the inspector of custodial services visited the prison and found multiple hanging points, including some that were said to have been removed.
Though some were removed after Tane’s death, the report said: “The most significant concern, however, at the time of the inspection was the multiple hanging points we observed in the cells.”
Nioka says: “When they said to us that they were going to deal with the hanging points … You think, ‘OK, so no other family’s going to go through this.’
“It’s like they just pick your hopes up and they just shatter you.”
When the inspector conducted a follow-up visit in 2024, the ligature points had been removed.
A spokesperson for Corrective Services NSW said the government was“committed to reducing all preventable deaths in custody”and had already removed hanging points from 800 cells across the state. An additional 145 cells were expected to be completed by July 2025.
The government had invested $16m in ligature point removal, the spokesperson said, which would “continue the extensive work that has already been undertaken across several facilities” to remove unsafe furniture and infrastructure.
Growing up, Tane’s siblings called him “golden child”. Family meant everything to him. He rarely left his mother’s side.
“He was a type of person that would make sure everyone had a bed, everybody had a feed,” Nioka says. “He’d take his shirt off his back and give it to anybody.”
Tane had big plans for his life. An immensely talented footballer, he set his sights on going pro.
He was being watched by scouts, Nioka says, and had made representative rugby league sides. His cousin, Bevan French, went on to play in the NRL.
But, at the age of 15, Tane suffered a serious injury during a game of touch.
“It just sent him into a deep depression,” Nioka says. “He stopped playing sports with his siblings and he just thought, ‘If I can’t do what I’m good at, what can I do?’”
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Tane’s first stint in custody changed him.
“He come home, he said, ‘Mum, it’s like, all the boys in there treat you like a family,”’ Nioka says. “So he got that sense of having another family.”
“And he thought, ‘Well, is this where I fit in now? Because I can’t fit in anywhere with my other brothers that I had on the football field or the cricket field.’”
Tane entered custody in 2015. He was held on remand from October that year until his death, and was moved to Tamworth prison in August 2017 so he could be closer to his Armidale trial.
On 19 September, a day before he was discovered hanging in his cell, his family saw him in court. Nioka remembers he put two fists up in the air, as if he was going to fight.
Then they were told to make an “emergency” visit to see him in hospital. Nioka found her son in intensive care, naked except for a pair of hospital socks.
“I was really shocked and stunned the way that nobody told us that we were going to find him like that,” she says. “And it just, it wasn’t making sense.”
Tane died two days later.
His funeral was a sight to behold, Nioka says.
“That beautiful boy, he just made friends everywhere he went,” she says. “The funeral director rang me two weeks after his funeral and said, ‘Nioka, I just want to let you know that in the last 30 years Tane’s had the biggest [funeral] … how can your son be 22 and over 3,000 people turn up?’”
At the inquest into Tane’s death, a senior NSW corrections officer offered up an explanation as to why it was so difficult to remove hanging points from the jail.
“Tamworth CC is a very old facility, heritage listed built in the 1700s [sic] and there are limitations to what you can do with changing infrastructure,” she said.
The explanation did not impress. Grahame, the deputy state coroner, described it as “unacceptable”.
“The limitation of lethal means is one of the most reliable methods of reducing suicide,” she said. “Coroners have been recommending the removal of hanging points for many years. The issue must be taken seriously.
“Thirty years on from the [royal commission into Aboriginal deaths in custody] it is unacceptable to suggest it would be expensive or difficult to achieve the elimination of hanging points in a ‘heritage listed’ facility.”
Nioka describes the coronial system as the “monster’s loophole”. It investigates serious failures in the corrections system, she says, but can do no more than make non-binding recommendations to address them.
She wants an independent body set up to investigate Aboriginal deaths in custody, armed with greater powers to compel change.
“I believe the number would dramatically start lowering … because then someone has to be answerable.”
In Western Australia, the family of Ricky-Lee Cound is experiencing similar loss and frustration. Their son, a Noongar man, died in 2022 aged just 22, while in custodyat Hakea prison – a facility with a “parlous” lack of ligature-minimised cells,according to the coroner.
The family said: “The fact that prison cells aren’t properly ligature-minimised is a clear indication that the authorities are neglecting their responsibility to protect vulnerable individuals.
“This isn’t just a statistic – it’s our boy Ricky’s life. And the truth is, nothing will bring him back. But we can’t let this happen to others.”
Dr Hannah McGlade, a Kurin Minang Noongar woman and law academic at Curtin University, describes the continuing deaths of Aboriginal people in custody as a “severe human rights violation”.
“[Removing hanging points is] a very straightforward matter and yet it simply hasn’t happened and many lives, largely Indigenous, have been lost as a result,” she says. “Aboriginal deaths in custody are a national and international shame and blight on Australia.”
Megan Krakouer, the director of the National Suicide Prevention and Trauma Recovery Project, says governments have been guilty of “wilful blindness” on issues including hanging points since the 1991 royal commission.
“That particular Royal Commission, that was really quite powerful,” she says. “And it’s been diminished in every single way because there’s no political will.”
The independent senatorLidia Thorpe, who is a Gunnai, Gunditjmara and Djab Wurrung woman, criticises the lack of action on hanging points by the major parties. “I can’t help [but] think that this is part of the ongoing erasure of my people, particularly because we are the most incarcerated,” she says. “It is the ongoing sophistication of the genocide.”
The WA Department of Justice said it had undertaken a comprehensive hanging point removal program since 2005.
A spokesperson said priority had been given to “facilities with the highest risk and need” and the state was also expanding services for those with complex mental health issues, including by building dedicated therapeutic accommodation and employing specialist mental health staff.
Tane’s son sometimes asks to hear his father’s voice. Nioka plays him recordings of prison phone conversations, taking great care in what she lets him hear.
She’s in no doubt about the reasons behind the gross inaction on hanging points.
“[Aboriginal prisoners] are marked as criminals,” she says. “But they’re still human beings, at the end of the day.
“They’re somebody’s son, they’re somebody’s daughter.”
Indigenous Australians can call 13YARN on 13 92 76 for information and crisis support; or call Lifeline on 13 11 14. Other international helplines can be found at befrienders.org