A Victorian coroner investigating the death of an Aboriginal woman in custody has endorsed sweeping changes to the state's bail system, finding the current laws are a "complete and unmitigated disaster".
WARNING: This story contains details that may distress some readers. Veronica Nelson's family has given permission to use her name and image.
Coroner Simon McGregor on Monday delivered his findings into the death of Veronica Nelson, who died alone in her cell in a Melbourne prison on January 2, 2020 after being arrested over shoplifting-related offences.
The 37-year-old Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman represented herself in court at a hearing where she was refused bail in the days before her death.
Coroner McGregor described the conditions under which Veronica lived out her final days in the prison before her death as "harrowing", and her death as "preventable".
As well as calling for bail law reform, the coroner has also referred prison healthcare contractor Correct Care Australasia to prosecutors after finding it may have breached the state's health and safety act in relation to Veronica's care.
"Veronica was loved and respected by those that knew her, yet Veronica, while alone in her cell at the Dame Phyllis Frost centre, passed away after begging for assistance for several of the last hours of her life," the coroner said.
"She was found the next morning on the floor of a cell in a prison built on the lands of the Wurundjeri and Bunurong people.
"That Veronica was separate from her family, community, culture and country at the time of her passing is a devastating and demoralising circumstance."
Over five weeks last year, the coroner heard multiple systems failed Veronica in the days leading up to her death.
The inquest heard Victoria's tough bail laws — which force many people accused of minor, non-violent crimes to clear enormous hurdles in order to be granted bail — were instrumental in placing Veronica into the prison cell where she lost her life.
Victoria's bail laws were tightened following the 2017 Bourke Street attack, when James Gargasoulas killed six people while on bail.
Coroner McGregor said the changes had been a "complete and unmitigated disaster", with negative effects "most obviously inflicted on the accused who are incarcerated, often for short periods, and for unproven offending of a type that often ought not result in imprisonment even if proven".
"I find that the Bail Act has a discriminatory impact on First Nations people, resulting in grossly disproportionate rates of remand in custody, the most egregious of which affect alleged offenders who are Aboriginal and/or Torres Strait Islander women," he said.
A panel of justice experts who gave evidence to the coroner last year unanimously recommended the Bail Act be reformed immediately.
Coroner McGregor said he endorsed proposals to amend the Bail Act "urgently".
In anticipation of the coroner's findings, the Andrews government this month announced it would move women's prison health care to public providers and flagged a willingness to reform bail laws.
Victorian government to 'carefully consider' findings
Veronica Nelson's mother Aunty Donna Nelson spoke outside court, describing her daughter as a "kind, caring and compassionate" woman who loved her family and culture.
She called on the public to demand changes to the state's criminal justice system.
"My daughter's pleas for help haunt me every night, and I can't stop hearing her voice," she said.
"Veronica did not deserve to die in such a cruel, heartless and painful way.
"Her death never should have happened.
"I want you to fight with me and make sure that no other mother has to bury her child due to the racism and cruelty of individuals and the racism and violence of a broken justice system."
Veronica's partner of more than 20 years, Uncle Percy Lovett, remembered her as a "kind and loving girl" who was treated "like she wasn't human" while in prison.
"The prison guards, doctors and nurses, and all the people in charge neglected her and let her die," he said in a statement read to court.
"They were cruel and racist. They lied to her, laughed at her, and told her to stop asking for help, all while she was dying."
Victoria's Attorney-General Jaclyn Symes said the government was continuing work on criminal justice reform, including bail reform.
"The death of Veronica Nelson was a tragedy — nothing less. Our thoughts are with Ms Nelson's family and friends today," she said.
"We thank the coroner for his work and will carefully consider his findings and recommendations."
Shadow Attorney-General, Michael O'Brien said the opposition would "closely review these recommendations and work constructively on any legislative changes proposed to achieve a more effective, fairer justice system for all Victorians that delivers a safer community".
Meanwhile, the Victorian Greens called for urgent bail reform as soon as parliament returns, "to reduce the over-imprisonment of First Nations people and the risk of further deaths in custody".
Victoria Police also said it would "take time to consider the findings and the recommendations".
Coroner highlights Veronica's 'inadequate' legal help
Coroner McGregor highlighted failures in Veronica's interaction with the justice system, including police officers' use of handcuffs on Veronica, errors made in a remand form and the fact Veronica represented herself at a court hearing in the Melbourne Magistrates' Court where she was denied bail.
Police also failed to inform the court that Veronica was Aboriginal.
The coroner also criticised barrister Tass Antos, who was engaged by the Law and Advocacy Centre for Women to assist Veronica, describing his engagement with her as "inadequate".
He said when Mr Antos met with her before her court appearance, he should have discussed things such as her personal circumstances, including her Aboriginality, her prior criminal history and any custody management issues.
"I am satisfied that Mr Antos could not have undertaken all those tasks within the very short time he spent with Veronica," Coroner McGregor said.
"The failure to perform all those tasks and the remarkably short period of time spent with Veronica falls short of the standard expected of a legal practitioner."
During the inquest, expert legal witnesses expressed concern that the onus was put on Veronica, in a culturally unsafe hearing before a magistrate, to disclose personal information that might have helped her case for bail over shoplifting-related offences.
In the end, the 37-year-old was denied bail and send to prison on remand.
Failure to transfer Veronica to hospital contributed to her death
Coroner McGregor described how Veronica called for help from staff, and relayed her worsening symptoms, 49 times using an intercom in her cell during the 36 hours she spent at the prison before she died.
"The sounds of Veronica's last pleading calls for help echoed around the courtroom when played during the inquest, prompting me to ponder how the people who heard them and had the power to help her did not rush to her aid, send her to hospital or simply open the door to her cell to check on her," he said.
When Veronica arrived at the maximum-security Dame Phyllis Frost prison, she was severely malnourished and had begun frequent bouts of vomiting.
At the time, she was withdrawing from heroin use.
The coroner said the treatment by prison doctor Sean Runacres was "inadequate" and demonstrated "significant departures from reasonable standards of care and diligence expected in medical practice".
The coroner said the doctor, who was working for private contractor Correct Care Australasia, had failed to provide a plan for Veronica's ongoing management, even though he "ought to have done so".
"I find that Veronica should have been transferred to hospital at the time of her reception to Dame Phyllis, and that corrections and Correct Care staff continually failed to transfer her to hospital thereafter, and this ongoing failure causally contributed to her death," he said.
In a statement, Correct Care Australasia offered condolences to Veronica's family and described her death as "tragic".
"We acknowledge the findings of the coronial inquest that relate directly to Correct Care Australasia and are currently reviewing those findings," it said.
The inquest previously heard that in a prison where up to 90 per cent of women suffer from some form of substance addiction, those women are often locked away in cells as they withdraw, vomiting and distressed.
Coroner McGregor said there was evidence of "pervasive stigma" at Dame Phyllis towards women who use injectable drugs.
He said that despite some prison officers showing kindness towards Veronica — through acts such as giving her cordial and a pair of socks — her overall treatment by corrections staff was "cruel and degrading".
The inquest previously heard unless there had been agitation for a full coronial investigation, the official record would have stated that Veronica's treatment in prison was "appropriate" and "there was nothing to suggest" her medical treatment did not meet the state's guidelines.
The coroner previously heard a combination of severe malnutrition, heroin withdrawal symptoms and a rare medical condition affecting Veronica's intestine all contributed to Veronica's death.
