Ms Grahame said such over-representation was accurately described as a national disgrace,and noted Mr Chatfield's inquest was not the first"impulsive Indigenous suicide"in custody she has presided over this year.

"I remain enormously troubled by the occurrence of these events,"Ms Grahame said.

"Once again it is incumbent upon me to stress that if we are to reduce the number of Aboriginal deaths in custody,we need to grapple with the underlying causes of over-representation.

"Quite simply,more young Aboriginal men like Tane must be diverted away from the criminal justice system if we are to reduce the number of Aboriginal deaths in custody nationally."

Ms Grahame said Mr Chatfield was first detained at the age of 14,and his death must be understood"in its context of real social injustice,ongoing dispossession and his lived experience of inter-generational trauma".

"Tane’s mother echoed this sentiment during the family statements when she told me directly
that Tane was killed by the prison system,"Ms Grahame said."I acknowledge the truth and pain of her words."

She said the issue of obvious hanging points was raised thirty years ago,at the Royal Commission into Aboriginal Deaths in Custody,but clearly remains unresolved today despite Coroners making recommendations for"many years".

Ms Grahame made a number of recommendations,including that Corrective Services conduct a"comprehensive audit"of all cell hanging points at Tamworth Correctional Centre and urgently remove any points identified.

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