Death in Custody: The Case of Tammy Shipley
Tammy Shipley, a 47-year-old Aboriginal woman with diagnosed schizophrenia and bipolar disorder, died in custody at Silverwater Women's Correctional Centre in New South Wales on December 20, 2022. The cause of death was hyponatremia due to water intoxication (polydipsia), a complication of her schizoaffective disorder. A coronial inquest is now examining the circumstances of her arrest and the actions of police and prison staff before her death.
Timeline of Events
Request for Arrest and Initial Police Interaction
On December 9, 2022, Shipley entered Macquarie Fields Police Station and requested to be arrested for her own safety. Police declined this request three times.
Later that day, Shipley stole goods valued at $574 from a Target store and was charged with shoplifting and trespass. She was issued a conditional release order. She then returned to the same shopping centre and stole items valued at $23.10 from a Woolworths store. She stated she wanted to be jailed.
Arrest and Transfer to Custody
On December 10, Shipley was arrested. Police reports noted no mental health history, despite at least four prior interactions with her. The court was not informed of her schizophrenia diagnosis. She was refused bail.
On December 11, Shipley was transferred to Silverwater prison. Shortly after arrival, she attempted suicide and was placed in the Mum Shirl Unit under 24-hour CCTV monitoring.
Court Appearance and Continued Detention
On December 14, Shipley appeared in court via video link and pleaded guilty to the Woolworths charges. The magistrate ordered her release, but a technical issue involving an uncancelled bail from the earlier charges resulted in her remaining in custody.
Final Days and Death
On December 18, 19, and 20, CCTV footage showed Shipley repeatedly drinking water from a red cup holding 300ml. On December 20 alone, she filled the cup at least 67 times between 12:33 AM and 11:51 AM, indicating consumption of a minimum of 20 litres of water.
- At approximately 10:00 AM on December 20, Shipley began vomiting.
- At 11:55 AM, Shipley collapsed on her bed, exhibiting vomiting, defecation, and spasms.
- The last physical cell check was recorded at 10:41 AM.
- Prison guards were unaware of her condition until 1:15 PM. Officers passed her cell at 12:27 PM and 12:41 PM but their view was obstructed by broken blinds.
- An alarm was raised when an officer attempted to speak to Shipley. Two prison nurses located her unresponsive at 1:35 PM. Resuscitation attempts were unsuccessful.
- Shipley was pronounced dead at 2:25 PM.
Systemic and Policy Context
"An interim ruling found Shipley was in an acute psychotic state from the time of her arrest and died as a result of inadequate mental health care."
Coronial Findings and Inquest
A coronial inquest into Shipley's death commenced in September 2024. The Supreme Court of NSW ruled that the coroner’s jurisdiction extends to examining the circumstances of Shipley’s arrest and her detention while mentally unwell. The inquest is led by state coroner Teresa O’Sullivan.
The inquest is assessing the adequacy of mental health indicators within police and custodial management systems. The coroner has proposed system updates comparable to those used to flag a history of family violence.
Corrective Services NSW policy requires an immediate response to signs including vomiting, twitching, and seizures. These signs were not acted upon in Shipley’s case.
Staff and Facility Reports
Prison nurse Jade Coupland reported inadequate resources and repeated coronial recommendations that have not been acted upon.
An autopsy determined the cause of death to be hyponatremia from extremely low sodium levels, attributed to polydipsia and complications of schizoaffective disorder.
"Prisons have become 'new asylums,' noting that approximately 1,000 people with schizophrenia are held in NSW prisons at any given time."
— Forensic psychiatrist Dr. Olav Nielssen