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Why the health sector must engage with the coronial findings into the death of Veronica Nelson

***Aboriginal and Torres Strait Islander readers are advised this article contains details of a person who has passed in traumatic circumstances. Statements and photos are included with permission***

A Victorian coroner’s investigation of the death in custody of Veronica Nelson, a proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman, is important reading for the health sector, including those working in education, policy, service delivery and public health.

Veronica Nelson passed away on 2 January 2020 at age 37. She was remanded in custody at the time, having been refused bail for relatively minor, non-violent offences. The coroner found her death was preventable had she been transferred to hospital, and that she died of cardiac failure resulting from electrolyte disturbances.

“Whether the vomiting, diarrhoea and malnutrition were predominantly caused by Wilkie Syndrome, or opiate withdrawal, or both equally, is immaterial to this point. The evidence is that Veronica’s condition could have been addressed and corrected upon a transfer to hospital, where Veronica would have received intravenous fluids and electrolyte replacement,” said the Coroner.

The 366-page report by Coroner Simon McGregor details how multiple systems, services and people repeatedly failed Veronica Nelson, including when police handcuffed her.

The handcuffing was unjustified and a disproportionate restriction of her rights and “one example of many, in which individuals charged with Veronica’s care followed internal (and at times informal) practices, without turning their minds to the justification or proportionality of that practice and whether they had any other less restrictive options available to them,” reported the Coroner.

Law reform matters

The report illustrates the importance of all levels of the health sector ­ – from individual practitioners to professional organisations, services, policymakers and health ministers – engaging strenuously with law reform.

The Coroner draws a clear line between changes to Victoria’s Bail Act in 2018 and Veronica Nelson’s incarceration.

In 2018, the rate of imprisonment per 100,000 of the adult population was considerably higher for Aboriginal adults than for all adults. Aboriginal people comprised 8.2 percent of all prisoners; Aboriginal women comprised 10 percent of female prisoners in Victoria. Overall, most adults in prison were serving a prison sentence.

A year after the 2018 Bail Act changes were introduced, the statistical picture had changed markedly, the Coroner said.

By June 2019, imprisonment rates for all adults and Aboriginal adults had increased, and the rate at which Aboriginal women were imprisoned had nearly doubled. Aboriginal prisoners comprised more than 10 percent of all prisoners, and Aboriginal women made up 14 percent of all female prisoners.

By this time more than a third of all adults in prison were unsentenced, nearly half (47.7 percent) of all Aboriginal prisoners were unsentenced, and 86 percent of Aboriginal women were unsentenced on reception. Forty-five per cent of unsentenced men and 61 percent of unsentenced women were remanded in custody for alleged offences not involving violence.

“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,” said the Coroner.

He said the “complete and unmitigated disaster” of the 2018 changes “is 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 if proven”.

“Short periods in custody are destabilising and often serve to exacerbate issues underlying the person’s alleged offending by producing loss of housing, work or income, the breakdown of relationships and support networks, and disrupted access to treatment and other services. These outcomes are plainly antithetical to rehabilitation and adversely affect the underlying social issues that drive offending,” the Coroner said.

“The remand rates caused by the reverse onus regime of the Bail Act also increase the likelihood that an accused will plead guilty to offences even where the evidence may not sustain a finding of guilt. The provisions incentivise a plea of guilty to avoid time in custody where the prospects of bail are limited. A guilty plea is the more direct route to freedom.”

While the Victorian Government has promised to reform the Bail Act, many other states and territories are continuing to implement laws that will have predictable adverse outcomes, especially for First Nations peoples, just as were predicted for the 2018 changes in Victoria.

The Coroner said: “Governments have had the answers to the problems identified in Veronica’s case for over thirty years. The findings and recommendations of RCIADIC [Royal Commission into Aboriginal Deaths in Custody] were reasonable and implementable, and they should have resulted in the type of widespread systemic changes that could have prevented the tragedy of Veronica’s passing from occurring.

“Aboriginal and Torres Strait Islander people have been calling on Governments and their institutions for decades: to stop locking up their communities for minor offences, to stop putting their children in prison, and to stop subjecting their people to systemic discrimination.”

Improve prison healthcare

The Coroner’s report also provides many reasons for wider and more concerted health sector engagement with improving the safety and quality of healthcare for people in custody and prisons.

Correct Care Australasia (CCA), a private company contracted to deliver primary healthcare in 13 public prisons, failed to provide Veronica Nelson with care equivalent to that she would receive in the community, a breach of a critical obligation it owed her, the Coroner found.

This was also a significant failing on the part of Justice Health, given its responsibility to ensure its contractor CCA had implemented the prescribed standards.

The report highlights many critical safety and quaklity issues, from incomplete medical records to poor systems and communications, to poor relationships between health professionals. It also found that women prisoners have lesser access to health services than male prisoners.

Even after Veronica Nelson’s death, systems failed her. The Coroner is scathing about a Justice Health report into her death, noting that it had many errors and omissions, and was “grossly inadequate and misleading”.

He also found the Justice Assurance and Review Office (JARO) review of Veronica’s passing to be “grossly inadequate and misleading”, and found that CCA failed to provide critical information to Justice Health following Veronica Nelson’s passing.

“CCA’s failure to undertake a root cause analysis or similar internal review at the time of Veronica’s passing was contrary to the requirements of the Justice Health Quality Framework; and Justice Health’s failure to ensure that CCA undertook a root cause analysis or similar internal review at the time of Veronica’s passing was contrary to the requirements of the Justice Health Quality Framework.

“Had Veronica’s passing not proceeded to coronial inquest, the findings of the JARO Report, Death in Custody Report and formal debrief would have remained as the only official investigations pertaining to this tragedy. It is a deeply concerning prospect to contemplate,” said the Coroner.

“The disturbing “don’t ask/ don’t tell” arrangement that DJCS and CCA appear to have had with one another is a matter of grave public interest and goes part of the way to explaining how so many continual and repeated systemic failings were permitted to occur in this case.”

Drug dependency services needed

The Coroner also highlighted links between the lack of alcohol and drug services and incarceration, and recommended that the development of culturally safe, gender-specific rehabilitation facilities for Aboriginal and Torres Strait Islander women must be prioritised.

Many witnesses told the inquest of a shortage of drug and alcohol supports available to people applying for bail. The Coroner said the need for culturally specific and gender-specific supports and services for Aboriginal women on bail was not new, and that there remains a “severe service gap,” with wait periods for the services that are available extending to four or five months.

“There is a clear link between a lack of available support or treatment for drug dependency and the remand of accused individuals with drug dependence,” the Coroner reported.

The report also underscores the impact of stigma in affecting the care of people with drug dependency, with the Coroner stating that staff’s failure to take seriously their obligations to Veronica was linked to an assumption that suffering and unwellness was ‘normal’ for a prisoner experiencing withdrawal. Drug-use stigma causally contributed to Veronica’s passing, the Coroner found.

“Normalisation of the suffering of women experiencing drug withdrawal results in the desensitisation of both CV [Corrections Victoria] and CCA staff to this presentation. Desensitisation to suffering rendered CV and CCA staff virtually unresponsive to Veronica’s persistent pleas for assistance and blind to her clinical deterioration. They collectively and continually failed to recognise that she was in need of urgent medical care.”

It is notable that the report mentions stigma far more often than racism – which is mentioned only three times in the report, according to a keyword search, despite its clear manifestation at systemic and interpersonal levels.

Cultural safety

The report highlights an urgent need to address a lack of cultural safety in policing, prisons, legal and healthcare systems.

Despite measures in place at the police station, court and prison intended to ensure Veronica could access culturally relevant support, her journey through the criminal justice system occurred without speaking to a single Aboriginal person employed in these roles, the Coroner found.

He said that Veronica Nelson, while alone in a cell at the Dame Phyllis Frost Centre, passed away after begging for assistance for several of the last hours of her life and falling silent during her final communication with a prison officer.

“That Veronica was separated from her family, community, culture, and Country at the time of her passing is a devastating and demoralising circumstance.”

The Coroner cites Professor Megan Williams, a justice health scholar and Wiradjuri woman, who told the inquest that it was 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…”

She said: “Our understanding in our culture about us being spiritual beings that are connected to our family and to our Country; to our Ancestors, as well as to descendants in our bloodlines; connections to our Song Lines; to our cultural responsibilities… all point to how inappropriate it is for us to die alone, to die in a disempowering institution, and to not pass on Country… to pass without having an opportunity for our spirit to become free and to convey what we need to convey from a cultural perspective.”

The Coroner acknowledged all the First Nations people who gave their time, evidence, and insights to his investigation, which had “benefited profoundly from their participation”. He acknowledged the emotional toll of their engagement in the coronial process.

Professor Megan Williams said the Coroner assembled a medical conclave and law and justice conclave as a way of bringing diverse experts together to dialogue, and make recommendations to the Coroner based on consensus where possible and clear considerations of evidence, legislation, policy, gaps and divergent views. This process could guide other inquests, she told Croakey.

Paying respect

The Coroner pays his respects to Veronica Nelson, writing that she was the eldest child of Aunty Donna Nelson, and the second child of her late father, Uncle Russell Walker. She was a sister to Belinda, Russell, Dwayne, Trisha, Richard and Jodie, and shared a long loving relationship with Percy Lovett, which began in her teenage years.

Veronica was loved and respected by those who knew her, the Coroner said, urging that she be remembered as she would have wanted to be remembered: “a wise, kind, strong, and proud Aboriginal woman, who saw the light of hope, beauty, and goodness in herself and in others, even through darkness”.


Statements from family and supporters

The Victorian Aboriginal Legal Service provided statements and photographs below.

Statement by Aunty Donna Nelson, Veronica’s mother

My name is Donna Nelson and I am Veronica’s mother.

Veronica was my first-born child, and she was my best friend. She was kind, caring and compassionate. She was loved by her family, her community, and her friends. She was a proud Aboriginal woman who loved her culture. She never harmed a soul other than her own.

Veronica did not deserve to die in such a cruel, heartless and painful way.

I chose for a long time not to hear or watch the tapes of her final moments, but I finally watched them during this inquest. It ruined me, and has changed me forever.  My daughter’s pleas for help haunt me every night, and I can’t stop hearing her voice.

To the law makers, I want you to sit and listen to Veronica’s final hours. I want her voice to ring in your ears until you realise that our justice system is broken. Veronica should never have been locked up. You were supposed to change bail laws to stop a white male monster from killing people, but instead you filled our prisons with non-violent Aboriginal women like my daughter Veronica. Our bail laws need to change now.

To Correct Care Australasia, you tried to cover up my daughter’s death. You silenced the nurse who tried to speak up about your doctors. I’m glad that you lost your contract. I’m glad that this inquest exposed you, and I pray that my daughter’s voice will expose all the other times you covered up deaths in the past.  My daughter’s death will not be in vain, and she will continue to lead the way for justice for others in death as she did in life.

To the Department of Justice, you were supposed to review the doctors and nurses and tell the Coroner what went wrong. Instead, you listened to my daughter’s pleas for help, and saw no wrongdoing. You too were exposed. You showed the world that your supposed independent reviews are self-serving and can never be trusted. That you too are a part of this broken system, and you too need to be held to account and change.

This inquest showed that Veronica was failed at every level of the justice system – from the moment she came into contact with police on 30 December 2019. When she travelled on the tram that Monday afternoon, the police saw an Aboriginal woman and bee-lined for her. It was this profiling that led to her horrific death where her final words at 4am were calling out for someone to help her. She called out for her deceased father. That’s how much pain she was in.  The response from the prison guard was to tell her to stop screaming as she was disturbing the other prisoners. As her mother, this will haunt me until the day I die. I hope it haunts all of you who didn’t help m