The crucial 23 minutes that could have saved Tammy Shipley’s life

Jails and police cells have always been dangerous places for Aboriginal people, but it beggars belief that in 2024 an inquest can be told authorities took 23 minutes to begin CPR on a woman with a history of illness after staff first spotted her lying prostrate on the floor.

Those minutes were the crucial period that could have saved Tammy Shipley’s life.

Prison staff had already failed to complete multiple physical checks over a period of several hours, during which time she experienced seizures and slumped off her bed onto the ground. When prison staff eventually opened her cell, Shipley did not respond, and they tried to resuscitate her. An ambulance arrived 20 minutes later. An hour and 10 minutes after staff first noticed her lying on the ground surrounded by her own body fluids, Shipley was pronounced dead.

Tammy’s mother and legal guardian Vicki Shipley at her home in Padstow.Credit: Flavio Brancaleone

The 47-year-old mother of six died at Silverwater Women’s Correctional Centre on December 20, 2022, after being arrested for stealing $23.10 worth of goods from Woolworths, trespassing and breach of bail more than a week earlier. She had a history of drug addiction and had been diagnosed with schizophrenia and bipolar disorder as a teenager. Unbeknown to prison staff, Shipley had been consuming massive quantities of water due to a delusion of extreme thirst, depleting vital sodium content in her blood.

Detective Senior Constable Salim Trad, the officer in charge of the coronial investigation, agreed it had taken “far too long” for Corrective Services to assist Shipley after she was first seen lying on the floor. “It’s a matter of life and death,” he said. “With CPR, seconds count.”

The Royal Commission into Aboriginal Deaths in Custody, delivered in April 1991, was supposed to be a watershed moment for our nation. Established in October 1987, the commission looked at the circumstances surrounding the deaths of 99 Aboriginal and Torres Strait Islander people in detention. It produced 339 recommendations.

There have been some changes, but these deaths keep happening. According to Attorney-General Mark Dreyfus, by 2023 more than 570 Aboriginal and Torres Strait Islander people had died in prisons and police operations since the royal commission ended. One of them, the 2020 death in custody of Victorian Veronica Nelson, has resulted in the reform of that state’s bail laws.

Both counsel assisting the inquest, Dr Peggy Dwyer, SC, and Shipley’s family, including her mother, Vicki, supported the Herald’s application to use video and imagery captured by CCTV camera that was ignored by authorities during those precious minutes when her life may have been saved.

The footage is confronting, but we believe it illustrates the shocking reality of institutional neglect.

Shipley’s inquest is expected to continue until the month’s end, but her unnecessary, tragic and lonely death at Silverwater Women’s Correctional Centre is emblematic of the fact that the most vulnerable members of the prison population suffer disproportionately from the effects of understaffing, institutional indifference and inadequate healthcare – among them, those in need of mental healthcare and Indigenous Australians.

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