Veronica Nelson always feared ending up in prison.
The family of Veronica Nelson have granted permission to use her image.
"She was worried about how prison staff would treat her," her partner Percy Lovett told a coronial inquest into her death this week.
Heartbreaking moments from the final two days of Veronica's life may help us understand why.
Like the moment prison officers came to her locked cell and offered her paracetamol and anti-nausea medication.
A sign on the door read "do not unlock", and so it remained closed to imprison the gravely ill 37-year-old woman inside.
Instead, officers pushed the pills through a flap in the door.
The inquest heard a nurse had to prise open Veronica's fingers to actually put the pills in her hand, "because they were cramped into a claw".
The increasingly urgent intercom calls Veronica made as a rare medical condition and heroin withdrawal triggered vomiting and cramps also shed light on how she sought to get the help she needed and the response she received.
Her cause of death was ruled to be complications from Wilkie Syndrome, which affects the small intestine, "in the setting of withdrawal from chronic opiate use".
To begin with, the Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman's voice was calm and gentle.
She used please multiple times as she asked for a drink to combat the dehydration brought on by sustained bouts of vomiting.
Later, she asked for a blanket, but the prison officer who replied told her they'd have to check because, for reasons they didn't explain, "we don't have the keys to open the door".
She made another attempt to explain to the officers what was happening, telling them "I need help, I'm cramping something shocking … I need help, badly, badly".
Hours later, Veronica was no longer making full sentences, the audio of the intercom calls distorted by her wails of pain.
"Veronica never screamed or asked for help from nobody unless she really needed it," Mr Lovett told the inquest.
Veronica turned to drugs after loss of father
Veronica's mother, Aunty Donna Nelson, told the inquest her daughter had a special bond with her late father, who taught her about Aboriginal culture as a girl.
Aunty Donna said his death in 2014 had been deeply painful for Veronica, who struggled to speak about sorry business, turning to drug use at times to deal with her trauma.
In her final moments, Veronica was screaming out for her dad.
"When I read and heard that Veronica was crying out to her old man, that really got me," Mr Lovett told the inquest.
"Because I know how much pain Veronica would've been in, to cry out for her father the way she did.
The inquest heard in opening submissions that a nurse who inspected Veronica when she'd first arrived at the prison told the doctor "she thought they should send Veronica to hospital".
Veronica weighed just 33 kilograms, and the nurse noticed she needed to be physically supported to sit up in her chair, was "frequently incoherent" and had low blood pressure and a low heart rate.
But instead, Veronica was prescribed a "rapid withdrawal pack" of medication and put behind bars.
Aboriginal incarceration triples in past decade
For Australia's Indigenous communities, stories like Veronica's are far too common.
Counsel assisting the coroner, Sharon Lacy, told the hearing Veronica was one of 505 First Nations deaths in custody since the Royal Commission into Aboriginal Deaths in Custody handed down its final report in 1991.
And she noted several of the key recommendations made three decades ago may be relevant to Veronica's final four days.
That the standard of healthcare in prisons be the same as that available to the general public and staff be trained to understand and appreciate the history of Aboriginal health issues, history and culture.
That prison officers be trained to recognise when someone is at risk of death due to illness, injury or self-harm.
That police officers use arrest as a last resort in dealing with offenders and that an entitlement to bail be recognised in practice.
But on some measures, Victoria is going backwards in addressing the over-incarceration of Aboriginal people.
The coroner heard the number of Indigenous people in Victorian prisons has nearly tripled in the past decade, representing 10 per cent of the overall prison population, compared to 6 per cent in 2010.
And more Indigenous women are being held in prison on remand — they've not been found guilty or sentenced, but are waiting for their court matter to be heard.
As of June last year, 61.4 per cent of Aboriginal women in prison in Victoria were on remand, up from 25 per cent in 2012.
'A broken criminal justice system locked my daughter up'
Veronica was only accused of a shoplifting, an offence unlikely to ever carry a jail term, but the state's tough bail settings likely played a role in putting her in the cell where she would die alone.
It's also still not clear why she was seemingly abandoned to represent herself in a hearing where she asked for bail, in a hearing her longstanding lawyer told the coroner was full of "glaring absences" of relevant information about Veronica's health and custody management issues.
In the weeks ahead, coroner Simon McGregor will carefully scrutinise whether Veronica's Aboriginality or drug use affected the decisions made about her by the state's justice and prison systems.
The state's bail laws and the health response at the prison will be squarely in focus.
Aunty Donna hopes the inquest will help stem Aboriginal deaths in custody.
"But let's not lose focus," she told the coroner.
