Indigenous woman Veronica Nelson’s human rights ‘infringed’ before death in custody

Indigenous woman Veronica Nelson spent 15 hours lying in a “vomit-ridden” cell on New Year’s Eve despite her constant pleas for help, a coroner has found.

Veronica Nelson was on remand when she was found dead in her cell at the maximum security Dame Phyllis Frost Centre in Melbourne in January 2020. Picture: Supplied

A Victorian coroner has called for urgent bail reform and referred a prison healthcare provider to prosecutors following the death of indigenous woman Veronica Nelson in custody.

Coroner Simon McGregor on Monday handed down his long-awaited findings on Ms Nelson, 37, who was found dead in her cell at the Dame Phyllis Frost Centre at Deer Park in Melbourne’s west on January 2, 2020.

Mr McGregor said Victoria’s controversial bail laws, which were tightened in 2018 following the Bourke Street attack, had been a “complete, unmitigated disaster” and discriminated against First Nations’ Victorians.

Supporters arrive for an Indigenous smoking ceremony at the Coroners Court of Victoria during last year’s inquest. Picture: Joel Carrett

Ms Nelson, who weighed just 33kg and had a distended stomach, was on remand for minor shoplifting offences and outstanding warrants when she died from Wilkie’s syndrome in the setting of withdrawal from chronic opiate use.

Among his recommendations, Mr McGregor called for sections of the Bail Act to be repealed so Victorians charged with minor, nonviolent offences do not have to pass difficult “tests” to be bailed.

He said Ms Nelson’s treatment by prison staff was “cruel” and “degrading” and she was subjected to drug-use stigma that causally contributed to her death.

“(The) conditions under which Veronica lived out her final days are harrowing,” he said.

A general view of the Dame Phyllis Frost Centre prison. Picture: Mark Dadswell

The coroner referred prison healthcare contractor Correct Care Australasia to prosecutors after finding it may have breached health and safety laws during its care of Ms Nelson.

The referral was met with applause from Ms Nelson’s relatives and supporters who packed the courtroom.

Mr McGregor criticised the prison for not transferring Ms Nelson to hospital despite some staff believing she had the “worst case” of drug withdrawal symptoms they had seen.

Quoting a witness, Mr McGregor said there was a view among staff that prisoners had to “suffer” in order to be corrected.

The coroner criticised prison doctor Sean Runacres, who assessed Ms Nelson, finding his care was not comprehensive, his notes were “inaccurate” and she was not provided with a management plan.

Veronica Nelson with her partner of 20 years, Percy Lovett. Picture: Supplied

Ms Nelson did not have legal representation during her bail application, and Mr McGregor found it was “inadequate” that she met a lawyer for less than six minutes.

After she was remanded, Ms Nelson spent 15 hours lying in her “vomit ridden” cell on New Year’s Eve before she was transferred to a different cell the following morning.

During her 36 hours in custody, she made 49 calls for help or complaints via an intercom over her worsening symptoms, which included vomiting, nausea and cramping.

Ms Nelson was medically examined and given water-soluble electrolytes but continued vomiting while a nurse watched a movie on a computer.

Her calls for help stopped about 4am on January 2 before she was found dead nearly four hours later.

Speaking outside court, Ms Nelson’s mother Aunty Donna Nelson said her daughter did not deserve to die in such a “cruel” way and called on the government to implement the recommendations.

“My daughter’s pleas for help haunt me every night, and I can’t stop hearing her voice,” she said.

“This inquest showed that Veronica was failed at every level of the justice system.”

Attorney-General Jaclyn Symes said Ms Nelson’s death was a tragedy and the coroner’s recommendations would be carefully considered.