From the moment she entered prison, Veronica Nelson knew she wasn't well.
Aboriginal and Torres Strait Islander readers are advised this story contains images of a person who has died. Readers are advised the following details may distress some people.
"I feel sick, I'm spewing up," she told prison officers over the intercom from her cell.
The Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman had already told them she was withdrawing from heroin — but an autopsy later found she was also suffering from a rare medical condition that would later contribute to her death.
A five-week inquest before coroner Simon McGregor began on Tuesday to explore why the 37-year-old, whose family requested she be referred to as Veronica on second reference, ended up in custody in the first place, and why she died alone in a locked cell despite repeated pleas for help.
A packed room at the Coroners Court of Victoria heard in painful detail how Veronica's calls for help were received.
In three calls made on the morning of January 1, 2020, a day after her admission to the Dame Phyllis Frost Centre in Melbourne's west, Veronica asked for something to drink as cramping, vomiting and dehydration set in.
VERONICA: Can I please get some cordial?
PRISON OFFICER: Not at the moment, we're in lockdown
VERONICA: After lockdown, can I please get a drink?
PRISON OFFICER: I'll see what I can do, this intercom is for emergencies only.
VERONICA: Can I please get a drink now? Hello? Hello? Can I please get a drink?
The coronial court heard that when Veronica arrived at the prison a day earlier, a nurse who had initially assessed her was concerned at the way she was unable to sit up in a chair by herself, needed physical support at times and was "frequently incoherent".
The court heard the nurse said she was "alarmed" by Veronica's low blood pressure and low heart rate, and told the doctor they were working with that she believed she should be sent to hospital.
But the doctor observed Veronica looked "generally well", and instead she was admitted to the prison and prescribed her a rapid withdrawal pack including anti-nausea medication, paracetamol and the opioid drug suboxone.
Veronica found dead hours after cries for help
Counsel assisting the coroner, Sharon Lacy, told the court Veronica spent her final hours in a cell with a sign that read "do not unlock", and CCTV footage released by the court shows staff responding to calls for help by offering items through a metal flap in the door.
In the early hours of January 2, Veronica's calls for help escalated as her vomiting and cramping worsened.
Ms Lacy said paracetamol and anti-nausea medication was taken to Veronica and still dispensed through the metal flap.
She said the nurse had to prise open Veronica's fingers in order to pass on the tablets, because the cramping had become so severe that they had "cramped into a claw".
In one of her final cries for help, Veronica could be heard screaming for her late father, before declining an offer to be taken to the medical unit.
PRISON OFFICER: Ms Nelson?
VERONICA: Yes?
PRISON OFFICER: The only option is to go and stay in medical, but she probably can't give you anything else.
VERONICA: No.
PRISON OFFICER: What do you want to do?
VERONICA: I want to stay here.
PRISON OFFICER: Well, you'll need to try and stop screaming out, because once the other women start waking up they'll get pretty annoyed if you keep screaming. What do you want to do, you can go up to medical?
VERONICA: No.
PRISON OFFICER: You going to stay there?
Veronica did not reply to the final question, but could be heard breathing heavily.
The next morning, Veronica was found dead in her cell, with the shower running — hours earlier, she'd discussed with one of the prison officers how that might help soothe the cramps.
Her cause of death was ultimately found to be complications from the rare Wilkie Syndrome, "in the setting of withdrawal from chronic opiate use".
'She wasn't looked after properly'
For Percy Lovett, the loss of his partner of 20 years has shattered his world.
The 57-year-old Stolen Generations survivor says it was Veronica who showed him what it meant to form a "real family".
"[She] made me have a better look at life and that, showed me what a properly family is," he said.
He says Veronica was the brains of the relationship, sharing with him her considerable knowledge of Aboriginal culture.
"Whenever she would talk about Blackfellas, the stories she would come out with were unreal," he said.
"She knew a hell of a lot more than me."
Now, he wants answers on what happened in the four days after she was taken into custody.
"We're held accountable for when we make mistakes and that, and someone has definitely stuffed up in the system somewhere along the line, and they've gotta be held accountable for that," he said.
Veronica's mother, Aunty Donna Nelson, recalled her deeply spiritual daughter as a "best friend" who was also a mother to her six siblings and their children.
Veronica was resilient and had a fighting spirit. Veronica had a big personality and a beautiful laugh," the family said in a statement.
The inquest also heard how Veronica represented herself on the day she was remanded into custody facing shoplifting-related offences.
That and other aspects of the way her case was handled, including whether attitudes towards her Aboriginality or drug use affected her treatment, will be under the microscope in the weeks ahead.
Mr McGregor acknowledged the inquest would be "exquisitely difficult" for the family, and apologised in advance "if some of what follows for the next five weeks seems clinical or harsh with what is such sorry business".
The hearing continues.
