No charges will be laid over the death of an Indigenous woman in prison after Victoria's workplace safety watchdog determined there was not enough evidence for a prosecution.
Veronica Nelson, 37, died alone in her cell at Dame Phyllis Frost Centre in January 2020 after being arrested for breaching bail and suspicion of shoplifting.
The Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman became severely ill from opioid withdrawal and begged for help 49 times but was knocked back by prison guards and healthcare staff in the 36 hours before her death.
WorkSafe Victoria began an investigation in May 2022 into whether any occupational health and safety rules had been breached by the Department of Justice or prison operator Correct Care Australasia.
After more than two years, the regulator on Thursday said there was insufficient evidence of any breaches through failures in the prison systems and processes in relation to staff training or work instructions.
"After carefully considering an extensive amount of evidence, including material from the coronial inquest, WorkSafe has determined not to not take further action on this matter at this time," a spokesman said.
"WorkSafe acknowledges the ongoing pain and trauma Ms Nelson's tragic loss has caused her family, friends and community."
The decision not to prosecute those responsible for her daughter's death has left Aunty Donna Nelson heartbroken.
"I can't express to you the pain of seeing the people responsible for my daughter's death walk away unpunished," she said in a statement.
"What good is coronial process, the pain and heartache that we have to go through, if they just let these people walk?
"They're killing our children and not holding anyone to account."
Aunty Donna's lawyer Ali Besiroglu questioned what it would take for there to be accountability over an Aboriginal death in custody, saying Ms Nelson's case should be decided by a judge and jury.
"If there was ever a case with overwhelming and unquestionable evidence of gross negligence and risk to health and safety, this was it," Mr Besiroglu said.
"Summarily dismissing a prosecution under the guise of 'insufficient evidence' offends the very core of the rule of law - that no person is above the law.
"Veronica Nelson paid with her life for her petty offences. She deserved much more than a justice system designed to let her perpetrators walk free with impunity."
Coroner Simon McGregor in January 2023 declared Ms Nelson's death in January 2020 was preventable, called for bail law reform and found corrections had failed to provide her with adequate health care.
He handed down 39 recommendations, including an urgent review of the state's bail act - widely known as the toughest in the country.
The findings sparked changes to the state's bail laws designed to make it easier for lower-level offenders to get bail.
But even then, WorkSafe will not begin a prosecution if there is no reasonable prospect of conviction.
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