Good afternoon, David Estcourt here again, closing The Age’s blog covering the inquest into Veronica Nelson’s death in custody. We hope you found our coverage informative and useful today.

In the centre of the frame, flanked by supporters, are Nelson’s partner, Percy Lovett, and mother, Aunty Donna Nelson.Joe Armao

Nelson’s death, which happened in January 2020, has been ricocheting around the legal community for the last few years, with the final reckoning today at the Victorian Coroner’s Court.

There is now broad agreement, especially in the wake of gut-wrenching hearings and findings, that something must be done about Victoria’s bail laws. What that is will likely be debated in coming months.

We’ll leave you with a few quotes from family members and loved ones outside court:

“I want everyone to remember what happened to Veronica,” Percy Lovett, Nelson’s partner for 20 years, said.

“The Premier, every government minister, every head of a prison, every prison guard, every doctor and nurse in prison, every police officer, every lawyer and every magistrate. They have to see what happened to Veronica and to change.”

“No one should have to die in prison. No one should die in pain. No one should die alone in a prison cell.”

Aunty Donna, Nelson’s mother, also spoke outside the court. She said Premier Daniel Andrews, whose government passed the strict bail laws in 2017, should feel shame over the laws.

“To the Premier Daniel Andrews, you should hang your head in shame. You need to do your job and get our daughters out of prisons. No more cover-ups. No more unintended consequences. It’s time to save our daughters. It’s time to change the law. It’s time for Poccum’s law.”

Our court reporter Erin Pearson will continue to cover the case for tomorrow’s paper.

Thank you again for reading.

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3.46pm on Jan 30, 2023

‘Disturbing’: Coroner says apparent ‘Don’t Ask, Don’t Tell’ arrangement between Victoria’s prisons and the department

Coroner Simon McGregor said his investigation unearthed questions about the monitoring of deaths in custody by the Corrections Department, including what he described as a ‘Don’t Ask, Don’t Tell’-style policy which meant Nelson’s death might have never been properly examined.

At the time of Nelson’s death, the state government had contracted Correct Care, which the coroner referred to prosecutors, to provide services to inmates at Dame Phyllis.

McGregor labelled the relationship between the contractor and the government “deeply concerning”, and the apparent arrangement between Correct Care and the department as “a matter of grave public interest”.

“Had Veronica’s passing not proceeded to a coronial inquest, the findings of the [internal] report, the death in custody report, the formal debrief would have remained as the only official investigations pertaining to this tragedy,” he found.

“It is a deeply concerning prospect to contemplate. The disturbing ‘Don’t Ask, Don’t Tell’ arrangement between the department and Correct Care appear to have had with one another is a matter of grave public interest.”

That notion is reflected in comments made before the inquest findings were handed down by Nelson’s mother, Aunty Donna’s lawyer, Jeremy King, who said without an inquest, there is no doubt the community and Nelson’s family would never have learnt the truth of what happened.

“It shows these things can potentially get swept under the rug and that’s pretty alarming,” King says.

He said it goes part of the way to explaining how so many continual and repeated systemic failings were permitted to occur in this case.

“Each of these lines of inquiry could not be considered in a vacuum because Veronica is passing and tragically is not an anomaly. In 12 months after Veronica’s passing, four more women died at Dame Phyllis,” he said.

“This investigation poses some concerning questions about the operation of custodial healthcare in this state,” McGregor said.

“One of those women was also Aboriginal Torres Strait Islander. In 2020/21 there were at least 15 indigenous deaths in custody nationally.

“The apparent flaws in the provision of those services by the hybrid public authority contracted to provide in turn raise questions about the government’s monitoring these substantial funding arrangements for the provision of a service that is legally required to be provided to the equivalent standard as you all expect to receive in our community.”

He said those systems do not change nor improve when governments fail to conduct adequate reviews of Aboriginal deaths in custody, as was the case in response to Nelson’s death.

3.23pm on Jan 30, 2023

‘We know we need to do more’: Government acknowledges bail reform need

By Rachel Eddie

The Victorian government has just responded to the findings, acknowledging bail reform was needed to ensure the system did not have unintended consequences for people accused of minor offences.

Attorney-General Jaclyn Symes thanked the coroner and said the government would carefully consider his recommendations.

Victorian Attorney-General Jaclyn Symes.Paul Jeffers

“The death of Veronica Nelson was a tragedy – nothing less. Our thoughts are with Ms Nelson’s family and friends today,” Symes said.

“Our bail laws need to protect the community without having a disproportionate or unintended impact on those accused of low-level offending who do not present a risk to community safety.

“We know we need to do more in relation to criminal justice reform, including bail reform, and that work is continuing.”

3.14pm on Jan 30, 2023

O’Brien says Bourke Street attack must not be forgotten in reform push

By Rachel Eddie

Shadow Attorney-General Michael O’Brien has acknowledged the coroner’s findings and said the Coalition would closely review its recommendations and work constructively with the government.

“The Victorian Liberals and Nationals are committed to effective bail laws that protect the safety of the community whilst giving every opportunity to those in the criminal justice system to get on the right path,” O’Brien said.

“We will 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.”

O’Brien said the deadly Bourke Street attack in 2017, which prompted tighter bail laws, must not be forgotten in any proposed reforms.

2.50pm on Jan 30, 2023

A timeline of Veronica Nelson’s arrest and death in custody

Warning to Aboriginal and Torres Strait Islander readers:

This story contains images and references to a deceased person, and contains disturbing content.

2.36pm on Jan 30, 2023

Advocates call for urgent action on bail laws

By Rachel Eddie

The Victorian Greens released a statement in the moments after Coroner Simon McGregor handed down his findings, calling on Labor to reform the state’s bail laws as soon as Parliament returns next month.

“If you haven’t been convicted of a crime, you shouldn’t be in jail just because you are vulnerable,” Greens MP and justice spokesman Dr Tim Read said.

Greens MP Tim Read and party leader Samantha Ratnam.Chris Hopkins

“Yet Victoria’s bail laws continue to disproportionately imprison First Nations people, and the vulnerable, despite being found guilty of no crime, effectively for no other reason than their inherent disadvantage. It’s the very definition of discrimination.”

Read said the reforms should be consistent with the recommendations of the Royal Commission into the Aboriginal Deaths in Custody, and Labor had lacked the political courage to act.

“The tragic death of Veronica Nelson must be a turning point for this government to end its failed politicised justice policies. Now is the time for evidence-based government reform on bail.”

Principal lawyer at Robinson Gill Lawyers, Jeremy King, also said it was imperative the government acted on the coroner’s recommendations to ensure they’re enshrined into law as a matter of urgency.

“There is no doubt without the coronial process and without a court looking into this, we would never have gotten to the truth of what actually happened to Veronica,” King said.

“That’s not how it’s supposed to happen and speaks to the fact that we have so little oversight of what goes on in prisons.

“The thing utterly devastating about all of this is Veronica was in prison for a crime that doesn’t carry a crime of imprisonment.”

2.26pm on Jan 30, 2023

Coroner refers corrections contractor Correct Care to Director of Public Prosecutions

Coroner Simon McGregor has referred government prison contractor Correct Care to prosecutors after finding the company may have breached occupational health and safety laws over its treatment of deceased Aboriginal woman Veronica Nelson.

McGregor said that there was evidence of a sufficient level of suspicion which meant that he must refer the company to prosecutors to consider criminal charges.

The statement elicited cheers from supporters and loved ones of Nelson in the courtroom.

“I have found that Correct Care lacked a number of clear policies or processes for the safe medical management of their patients, many of whom were regularly presenting to them afflicted by various recognised medical risks,” he said.

“Although I accept that there are structural barriers present in custody, which can affect the way healthcare is provided in custody, and might in some circumstances, limit Correct Care’s capacity to mitigate particular risks, those structural barriers do not apply to the creation of clear policies and processes, which were absent in Veronica’s case.

“In those circumstances, I am satisfied that there is evidence of a sufficient level of suspicion or conjecture, for me to form the belief an indictable offence that may have been committed. I must therefore notify the Director of Public Prosecutions.”

McGregor also recommended that Correct Care Australia engage with Aboriginal communities to integrate culturally appropriate principles into the delivery of health services to Victorian prisons, and that this process should be ongoing.

McGregor then closed the court for the hearing to applause from a few attendees.

1.40pm on Jan 30, 2023

While a sick Nelson repeatedly complained of cramping, a nurse watched a movie

As Veronica Nelson slowly died, and fellow inmates in other cells attempted to soothe her desperate cries for help, the nurse responsible for her care watched a movie.

The court heard that as Nelson gradually languished and eventually died at Dame Phyllis Frost Centre, registered nurse Atheana George watched a movie on a computer at the facility.

Nelson had repeatedly told staff that her hands and legs were cramping, asking for medication and salt water to ease her discomfort.

As her condition worsened, she confided in a woman in a cell nearby. “I feel like I’m going to die,” she told the woman.

Speaking of Nelson’s last moments, Coroner Simon McGregor’s voice occasionally faltered.

1.12pm on Jan 30, 2023

Corrections staff treated Nelson in ‘cruel and degrading’ manner, coroner says

Coroner Simon McGregor has labelled the treatment of Veronica Nelson by corrections staff “cruel and degrading”, and found that it breached Section 10 of Victoria’s human rights charter.

“I’m satisfied that this treatment of Veronica by corrections staff was cruel and degrading,” he said on Monday.

He also found that the care and treatment by staff was influenced by drug use stigma, and that it causally contributed to Nelson’s death.

The Dame Phyllis Frost Correctional Centre, a women’s prison in Deer Park.Joe Armao

“The assumption that it is normal for patients withdrawing at Dame Phyllis to experience a level of suffering normalises such suffering and results in the desensitisation of both corrections and Correct Care staff to this type of presentation,” McGregor said.

“As a result of this normalisation, corrections and current care staff were not responsive to the obvious signs of Veronica’s clinical deterioration, and thereby continually fail to recognise that she was in need of urgent medical care.”

He summarised the mentality at Dame Phyllis Frost by quoting a witness who had provided evidence to the inquest: “If you’ve used drugs, when you’ve been told repeatedly not to, and you keep coming to jail for it, you deserve to suffer, and suffer you shall.”

12.42pm on Jan 30, 2023

How medical systems failed Nelson at her most vulnerable moments

Coroner Simon McGregor has described the last hours of Nelson’s life in the medical centre at the Dame Phillis Frost Centre, and examined the quality of her care.

The court heard that Nelson repeatedly vomited, experienced cramping in different parts of her body, and weighed just over 30 kilograms.

Veronica Nelson died in jail in January 2020 after calling for help about 40 times. Her family has given permission for her photograph to be used.

McGregor said that an unwell prisoner occupies a liminal space between two systems: the carceral and the clinical. The inquest identified substantial gaps in policies and procedures which are supposed to safeguard the health and wellbeing of prisoners, but which failed Nelson.

He found that risks to prisoners were not addressed by the department and that crucial information, like her repeated vomiting, cramping, and requests for cordial, was not passed between staff after shift changes.

“I find that the failure in corrections to establish proper procedures for information sharing between staff causally contributed to Veronica’s passing and meant that decisions in relation to Veronica’s medical care and custodial management were made on the basis of incomplete and inaccurate information,” he said.

“I find that with the failure of Correct Care and the department to clearly establish an adequate procedure for the medical clearance of a prisoner from the medical centre to a mainstream unit causally contributed to Veronica’s passing.”

Coroner hands down findings into death of Veronica Nelson

Key Posts

Closing the blog with a few words from Veronica Nelson’s loved ones

Latest Posts

‘Disturbing’: Coroner says apparent ‘Don’t Ask, Don’t Tell’ arrangement between Victoria’s prisons and the department

‘We know we need to do more’: Government acknowledges bail reform need

O’Brien says Bourke Street attack must not be forgotten in reform push

A timeline of Veronica Nelson’s arrest and death in custody

Advocates call for urgent action on bail laws

Coroner refers corrections contractor Correct Care to Director of Public Prosecutions

While a sick Nelson repeatedly complained of cramping, a nurse watched a movie

Corrections staff treated Nelson in ‘cruel and degrading’ manner, coroner says

How medical systems failed Nelson at her most vulnerable moments

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