Veronica Nelson was a proud Aboriginal woman with a deep love of her culture and family.
The family of Veronica Nelson have granted permission to use her image.
"You'd come first before her, you know, she'd go without a lot of stuff to help out the little ones or elderly people, a very kind young woman," is how Yorta Yorta elder Uncle Colin Walker remembers his great-niece.
"She was very polite, everything she said was thank you and please, a very polite young woman," he said.
Veronica's gentle nature should have worked in her favour when she found herself locked in a prison cell in January 2020, dependent on a person on the other end of an intercom system to respond to her polite calls for help.
Over the past five weeks a coroner's court has heard in detail of the days leading up to Veronica's death at Melbourne's Dame Phyllis Frost Centre.
Veronica had been arrested after being accused of shoplifting and was withdrawing from heroin while in custody after she was refused bail.
"I feel sick, I'm spewing up," she told prison officers in one of the many bids for help she made over the prison intercom during the two nights she spent in the cells in the lead-up to her death.
As well as experiencing withdrawal symptoms, the Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman also suffering rare medical condition affecting her intestine.
At various times, Veronica was told to stop asking when she'd see a doctor and that nobody could help her with her worsening vomiting and cramps.
VERONICA: I've spewed up everywhere,
PRISON OFFICER: Alright, no worries. That's OK. We'll have people in to clean in the morning.
On her first night at the prison, no-one checked on Veronica as her symptoms worsened, and the next morning her calls for help over the intercom were dismissed.
PRISON OFFICER: State your emergency.
VERONICA: Do I see the doctor yet?
PRISON OFFICER: No.
VERONICA: You said 10 minutes.
PRISON OFFICER: .. I will let you know ... What?
VERONICA: She said ... you said in 10 minutes
PRISON OFFICER: Well, things don't always go to plan so I will let you know when the doctor's here and when he's ready to see you, OK?
On the night she died, the inquest heard a prison officer lied to her several times about calling for a nurse on her behalf.
Uncle Colin said hearing the details of how his great-niece was treated by the court and prison systems in her final days "tears you to pieces".
'Utterly, appallingly undignified'
Much of the evidence aired in the past five weeks of hearings suggest the system was stacked against Veronica from the start.
To start with, she was in a prison, over a public holiday, where there are serious concerns the healthcare on offer isn't up to scratch.
"I don't believe the medical centre is well equipped to look after some of the more complex needs that women are suffering from when they come into our care," the general manager of the Dame Phyllis Frost Centre, Tracy Jones, told the coroner on Thursday.
Ms Jones was one of many, including former prisoner Kylie Bastin, who expressed concern about the standard of care offered through a government contract with private company Correct Care Australasia (CCA).
Ms Jones told the inquest she was concerned the "under-resourced" service was not well trusted by either corrections staff or female prisoners.
"I think that most of the [CCA] staff are there because they want to look after the women and do right by the women and they're under-resourced and they're busy and they don't have the retention of good staff and the working conditions aren't terrific," she said.
"Having said that, I don't agree that women should wait months and months for a specialist appointment."
Such concerns weren't new either. A 2017 report by the Victorian Ombudsman raised the alarm on prisoners facing unacceptably long waits to see a doctor.
In Veronica's case, the nurse on duty the night Veronica died didn't even read the patient file notes left by her colleagues before she went to take medication to Veronica, who had been crying out in pain to a prison officer over the intercom.
The nurse also failed to ask prison officers to open the cell door so she could assess Veronica properly, something she agreed at the inquest could have saved Veronica's life.
A medical panel told the inquest by that point, there had already been several missed opportunities to save Veronica from the profound malnutrition and vomiting bouts which contributed to her death.
Several panel members said from the very first assessment, it should have been clear that Veronica needed to be sent straight to hospital.
But the inquest heard observations of her vomiting weren't always passed from corrections staff to healthcare workers, highlighting dangerous gaps in communication and protocol.
"Utterly, appallingly undignified", and defying "any humane interaction" were phrases reached for by health panel experts as they tried to articulate the moral injustice of different moments in Veronica's final days.
On Friday, Correct Care defended its overall delivery of health services, telling the coroner it met the benchmarks in its contract with the state government and rejected suggestions the care Veronica received was "punitive".
But the company's chief medical officer, Foti Blaher, told the coroner he didn't believe the prison itself was well equipped to offer substantial medical care for women.
Dr Blaher said cells in what's commonly referred to as the medical unit of the prison "may have the word ward written on the front of them" but could not be considered a medical treatment unit in a clinical sense.
He said any reliance on those cells as a stepped-up level of medical care was "not appropriate" and women should instead be sent to hospital if they're not well enough to stay in their cell.
But it was in one of those "wards" that staff placed Veronica in her first night in prison, apparently so she could receive a higher degree of care.
Culturally safe care absent
Disturbingly, the coroner has heard details of the treatment Veronica received in prison may never have come to light, had the official reviews into her death in custody been taken at face value.
The inquest heard how a "debrief" which prison staff regarded as a chance to support staff and run a superficial eye over protocols was treated as an in-depth analysis by the justice department's internal review unit.
It resulted in a report that lawyers for Veronica's family said "wasn't worth the paper it was written on" and suggested prison officer Tracey Brown, who lied to Veronica several times about calling a nurse for her on the night she died, had performed admirably.
But while accounts of Veronica's treatment paint a distressing picture, her story isn't unique.
Three decades before her death, Australia's Royal Commission into Aboriginal Deaths in Custody warned the arrest of Aboriginal people should be a last resort, and that prison staff should be trained to recognise when someone's health was deteriorating.
Expert panels have told the coroner both the legal and prison systems that controlled Veronica's fate failed to offer her culturally safe care.
Outside the coronial hearings, Uncle Colin said he saw devastating parallels to the loss of another of his nieces in custody, Aunty Tanya Day.
"Going to both of these inquests, there's no difference to me, what happened to my two young nieces, no difference," he said.
Uncle Colin said his community was now throwing its arms around Veronica's grieving mother, Aunty Donna Nelson, as she processed the traumatic details of her daughter's final days.
"For this to happen, our hearts bleed for Donna," he said.
The 'reverse onus test'
Coroner Simon McGregor is yet to hand down his draft recommendations, but he has been given much evidence to ponder around another factor that put Veronica into the cell she would die in.
Over several years, Victorian governments have tightened the state's bail laws, including significant changes in the wake of the 2017 Bourke Street car attack.
It's created a situation where people charged with minor offences who are already on community corrections orders have to prove there are extraordinary circumstances justifying their release on bail.
This "reverse onus test" has created a climate where police officers rarely decide to bail someone themselves, legal experts told the coroner, instead sending it to courts where the laws were sometimes poorly understood and misapplied.
"I've had accused people arrested and remanded for stealing an ice cream, for stealing sushi, for stealing a bottle of orange juice and by virtue of being on bail, police have deemed it necessary to seek a remand," criminal law specialist Melinda Walker told the inquest.
The laws meant that when Veronica was arrested on December 30 in 2019 and charged with missing a court date and shoplifting, she had to try to clear the bar of proving exceptional circumstances existed.
Representing herself before a magistrate, due to a series of other failings in the system, Veronica explained her partner Percy Lovett was there in court to support and her mother was unwell and needed her by her side.
But the magistrate ruled that was not enough to justify bail, and so Veronica was sent to prison on remand.
Legal experts told the inquest they were disturbed by the way the system placed huge burdens on Veronica to disclose, in culturally unsafe spaces, personal information that might have helped her case.
The panel agreed the state's bail laws needed to be changed urgently to prevent more vulnerable people like Veronica from ending up behind bars unnecessarily.
"Until and unless there are amendments to this Bail Act, more people will be remanded, more people who don't deserve to be remanded or are not required to be remanded," Ms Walker said.
"It has significant impacts and compounds the underlying reasons for somebody's offending in the first place."
Unsurprisingly, the tightened bail laws have fuelled a surge in the number of prisoners on remand.
Most of them are waiting in cells for a court date that won't actually result in them being sentenced to jail.
The coroner heard around 45 per cent of prisoners released from jails left without having served a sentence.
For women, that rose to 60 per cent.
The inquest heard for many of these people, who hadn't committed serious crimes and didn't pose a threat to the community, incarceration simply disrupted their access to housing and support services, sometimes severing their links to families.
Given many of them are battling profound trauma and suffering from health issues around substance abuse, the net effect is sending them backwards in a costly exercise that delivers no tangible community gain, experts told the coroner.
It's something that's causing concern and more pressure for the prison system too.
"This revolving door of women coming in on remand in really short bursts creates this churn that it's hard to resource for," Dame Phyllis Frost Centre general manager Tracy Jones said.
Calls to reshape justice system
It's not a new observation.
A Victorian parliamentary committee recommended in March the state government urgently overhaul the bail laws due to the harm they are causing to the most vulnerable people in the community.
When asked about the inquest's evidence, the Andrews government has repeatedly declined to comment, saying it would be "inappropriate" while the coroner considers the evidence.
But at the same time the government is working to progress truth and treaty processes, it's facing calls from those who've given evidence to the inquest to walk the walk by giving more Aboriginal people the power to reshape colonial institutions that have long been instruments of harm for Indigenous families.
Expanding the role of the Koori Court to cover bail hearings, measurable standards of cultural competency training and better support for Aboriginal liaison officers in the justice and prison system are just some of the reforms proposed by witnesses during the hearings.
"I think the justice system has just fallen to pieces, far as I'm concerned," Uncle Colin said outside court.
"Because there's no protection there for our young women in cells, which there should be, they're supposed to be qualified.
"Are they qualified to look after our young women when they go in there?
