Yorta Yorta woman Veronica Marie Nelson made repeated calls for assistance in the hours before she was found dead in a maximum security prison cell, a coronial inquest has heard.
The 37-year-old, who also has Gunditjmara, Dja Dja Wurrung and Wiradjuri heritage, died at the Dame Phyllis Frost Centre on 2 January 2020, four days after being arrested because she had failed to attend a sentencing hearing for a shoplifting offence.
Recordings from the prison intercom system were played in the opening address of a five-week inquest into her death which began in the Melbourne coroner’s court on Tuesday.
In the recordings, Nelson can be heard crying in pain and telling prison officers, “I need help, I am cramping something shocking”. In the last recorded call for assistance, she is crying so loudly that the prison officer warns her to be quiet, in case she wakes up other prisoners.
Nelson was arrested on 30 December 2019 outside Southern Cross station and denied bail by police. On 31 December she represented herself at a bail hearing at the magistrates court. A duty lawyer for Victorian Legal Aid spoke to her prior to the hearing but did not represent her.
The court refused to release Nelson under the state’s strict bail laws, and she was taken to the Dame Phyllis Frost Centre.
The council assisting coroner Simon McGregor, Sharon Lacy, said the inquest will examine the state’s bail laws as well as the quality of supervision and medical care Nelson received while in prison.
An autopsy listed Nelson’s cause of death as complications of Wilke’s syndrome in a setting of acute opiate withdrawal – a condition which can cause pain, nausea and severe vomiting, which can lead to fatal electrolyte imbalances.
“She may have passed of natural causes, but if it could have been avoided, it should have been,” said Lacy.
What happened once Veronica Nelson got to prison
In her opening address Lacy outlined the events leading up to Nelson’s death.
Nelson was severely underweight – weighing just 33kg – and had been vomiting regularly since she arrived at Dame Phyllis Frost Centre, on the afternoon of 1 January 2020, Lacy said.
Lacy said a nurse who completed her initial health exam said she was “very concerned”.
The doctor who saw Nelson at the same time said she “looked generally well”, Lacy said. He gave her a rapid withdrawal pack, which included nausea medication and drugs to assist with opiate withdrawal.
Nelson was held in the medical ward overnight where she vomited repeatedly and made numerous requests for help on the intercom to prison officers. She was brought a drink at 7am and began reporting bad cramps at 7.31am.
She made 10 more requests between 7.30am and 10.15am, asking for a drink and to see the doctor. The court heard audio of a prison guard telling her at 10.15am: “It’s not an emergency. Stop asking.”
That afternoon she was transferred to the Yarra unit. Her cell was locked down at 7pm.
Lacy said Nelson was heard “screaming out in pain” from 9pm until after 4am, when she suddenly stopped.
At 1.37am, Lacy said a nurse gave Nelson some paracetamol and a Maxolon tablet, an anti-nausea medication. The nurse later told coronial investigators that she had to prise Nelson’s fingers open to place the tablets in her hand, because “they were cramped into a claw”.
Between 2am and 4am, Nelson made repeated calls on the intercom to prison officers saying she was “cramping badly”.
On the second last call, at 3.56am, a prison officer suggested she take a shower and said: “Ms Nelson you need to try to stop because you are keeping the other prisoners awake.”
On the last call, at 3.58am, the prison officer asks Nelson if she would like to go to the hospital ward. Nelson, who is crying on the call, says: “I want to stay here.”
At 7.50am prison officers opened Nelson’s cell door because she had not responded to the morning roll call.
She was found naked on the floor, in the foetal position, with her hands “clenched like claws,” Lacy said. The shower was running and the cell was flooded. A code black medical emergency was called, but the prison nurses who responded said it appeared Nelson had been dead “for quite some time”.
Nelson’s partner of 20 years, Percy Lovett, told the court that Nelson was a very strong and private person. “She wouldn’t have been crying out like that, especially to the officers, unless something was really wrong,” he said.
Lovett said Nelson was “one of a kind,” and losing her had only got harder as the years had gone on.
A systemic issue
Nelson is one of 505 Aboriginal and Torres Strait Islander people to die in custody since the royal commission into Aboriginal deaths in custody handed down its final report in 1991. Five of those deaths occurred this year.
Lacy said preventing further deaths in custody was a key aim of the inquest. The inquest scope includes the examination of systemic issues, including whether Nelson’s status as an Aboriginal woman and a drug addict affected the way she was treated by the justice system.
It will also look at issues of remand and bail, which Lacy said disproportionately affect Aboriginal women. As of 1 June last year, 61.4% of all Aboriginal women in custody in Victoria were on remand, meaning they had not been convicted and sentenced to jail on the offence for which they were in custody.
“[Nelson’s] offending had never given rise to a sentence of imprisonment, but she had been held on remand three times,” Lacy said.
Nelson’s mother, Aunty Donna Nelson, told the court that while preventing similar deaths must be a priority, her focus was on seeking justice for her “daughter, best friend and sister”.
“The lessons learned from this inquest must stop my people from dying in custody,” Aunty Donna Nelson told the court. “But let’s not lose focus. This inquest is first and foremost about Veronica, and how a broken criminal justice system locked my daughter up to die even when she was crying for help over and over.”
