A panel of medical experts has told a coronial inquest that clear warning signs should have prompted prison health workers to send Veronica Nelson to hospital the day before she died, "without dignity", alone in her cell.
The family of Veronica Nelson has granted permission to use her image.
On Thursday, the inquest heard that Veronica was in severe physical and psychological pain when she died in the early hours of January 2, 2020, at Victoria's maximum-security Dame Phyllis Frost women's prison.
Forensic pathologist Yeliena Baber this week told the court that the 37-year-old effectively died from severe malnutrition, which had been made worse by heroin withdrawal and a rare medical condition known as Wilkie's syndrome, which constricts the intestine and causes vomiting.
The expert medical panel — which includes several doctors with experience across emergency medicine, gastroenterology and drug addiction — agreed that Veronica's life could probably have been saved if she had been sent to hospital on the morning of January 1, after prison doctor Alison Brown noted her abnormally high pulse.
The panel advised that, around this time, Veronica was "grossly malnourished" and her copious vomiting, racing heart rate and dehydration should have made clear the need for urgent hospital care.
Several panel members also expressed concern that Veronica's human rights were breached during her time in prison.
"Making her clean up her own vomit while the nurse is making an assessment of her mental state defies any humane interaction," addiction medicine physician Yvonne Bonomo said.
Deteriorating health should have been 'very apparent'
Gastroenterologist Sally Bell said the way the Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman died, alone, was "without dignity" and "unnecessary".
"All of the people involved need to reflect on that, not just whether one individual was more at fault than another," Dr Bell told the inquest.
Dr Bell said there was no one "turning point" after which Veronica's life was unable to be saved, but a "continuum" where her chances of survival diminished as prison staff failed to act.
Fellow gastroenterologist Christopher Vickers told the inquest it was clear that Veronica was a "proud and dignified" woman.
"The way she died was utterly, appallingly undignified," he said.
The court heard that Veronica's body mass index (BMI) was around 13 when she died, and patients suffering from a disease such as anorexia nervosa would be admitted to a medical unit for stabilisation if their BMI fell below 15.
Panel members noted that opportunities to escalate Veronica's care were missed, due to poor communication between Corrections Victoria staff and healthcare workers employed by contractor Correct Care Australasia.
"If [the staff] had been communicating with each other, the deterioration would have become very apparent and the need to act would have become very apparent," Dr Bonomo said.
She said reaching that understanding was not a case of one missed data point or observation, but Veronica's overall presentation and underlying vulnerabilities.
"When you see someone like Veronica, you have to have a low threshold for acting on presentations of ill health," she said.
Differing views on first doctor's assessment
While the panel found multiple opportunities to save Veronica were missed, it held mixed views on whether the first doctor to assess Veronica, Sean Runacres, made a reasonable decision not to admit her to hospital.
A minority of panel members, several of whom had worked in prison settings, said it might have been reasonable to keep Veronica at the prison for the first night, and observe her condition closely.
But they agreed not enough planning was done to ensure Veronica was closely monitored and trigger points for an escalation of her care were not identified.
The panel also agreed that the nurse who was present for that assessment, Stephanie Hills, should have done more to escalate concerns that she told the inquest she held about Veronica's health at the time.
Panel members noted that, in a healthcare team, being able to refer disagreements upwards and resolve them to the satisfaction of all parties was critical.
Prison health researcher Megan Williams, who is a Wiradjuri woman, said Veronica never received culturally safe care in the prison, where she was not given access to an Aboriginal health professional who could have advocated for better care.
She also noted that, despite Veronica actively asking for help and following up on the times she was told a doctor would be available or her lockdown would end, she was not met with with the help she needed.
"It's extremely … damaging for an Aboriginal person to pass away in an institution, in a colonised setting where Aboriginal people have very little power to shape that system to respond to our needs and to respond to our cultures," Professor Williams said.
She said Veronica's physical and psychological pain as she died was made worse by the fact she was without her community and away from her traditional lands.
Some panel members also recommended health workers in the prison — where up to 90 per cent of women are withdrawing from alcohol or drugs — be required to maintain specialised training in addiction medicine.
The inquest continues.
