Damning coroner’s finding lays groundwork for ‘disaster’ bail laws to be reformed

A coroner has paved the way for significant changes to the way Indigenous Victorians are treated by the criminal justice system after handing down damning findings into the death in custody of Veronica Nelson.

Coroner Simon McGregor, who was brought to tears during a four-hour-long reading of his findings, took aim at a litany of systemic failures within the criminal justice, health and corrections systems he said led to Nelson’s preventable death in inhumane and degrading circumstances.

A still from a video released during the inquest showing Veronica Nelson inside a prison cell.

Victoria’s current Bail Act was “incompatible” with the Charter of Human Rights and discriminatory towards First Nations people, and 2018 changes to the law a “complete, unmitigated disaster”, resulting in grossly disproportionate numbers of Indigenous women being incarcerated.

Taking aim at the failure of the government to implement the recommendations of the Royal Commission into Aboriginal Deaths in Custody, McGregor said if this had been done 30 years ago, Nelson would still be alive today.

He said from the time of her arrest on December 30, 2019, to her death four days later at a women’s prison, Nelson was culturally isolated and her human rights repeatedly breached.

“Veronica was loved and respected by those who knew her. Yet Veronica, 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,” McGregor said.

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.

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

Nelson was arrested on Spencer Street on December 30, 2019, and taken to a nearby police station for questioning on suspicion of shoplifting. But instead of being released on bail from the station, she was transferred to Melbourne Magistrates’ Court where she was placed on remand until a court date weeks later.

Over the following two days, she made 49 calls for help over the prison’s intercom while heroin withdrawal and an undiagnosed medical condition ravaged her body.

She was found dead in her cell on January 2, 2020, lying in the fetal position. Ambulance officers believe she had been dead for some time.

An autopsy found Nelson had the undiagnosed medical condition Wilkie’s syndrome, a rare but potentially life-threatening gastrointestinal condition.

In a subsequent review of the death, Dame Phyllis Frost general manager Tracy Jones said she was proud of the way Nelson was treated in her final hours and her calls for help had been “sensitively managed”.

But McGregor said the system failed Nelson from the moment she set foot in the police station.

He said police had the power to release Nelson on bail but didn’t, and had already decided to remand the 37-year-old before her interview was complete.

Then, at Melbourne Magistrates’ Court she appeared alone, without a lawyer, where bail was refused.

The coroner said changes to the Bail Act made in 2018, following the Bourke Street killings, had resulted in the number of Aboriginal women being held in custody nearly doubling.

This, he said, had seen people facing prosecution for low-level crimes and repeat bail offences – who posed no risk to the community – routinely remanded in custody.

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

McGregor recommended allowing vulnerable accused to make more than one application for bail without having to establish that new facts or circumstances existed in their case.

“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,” McGregor said.

Throughout Nelson’s time at Dame Phyllis Frost Centre, she came into contact with a number of health care staff employed by Correct Care Australasia as part of a private contract with the government.

Recordings of those interactions were played during an inquest last year where it was revealed Nelson repeatedly asked to see a doctor only for Corrections Victoria staff to say her cries for help were keeping other prisoners awake.

McGregor said if an ambulance had been called at any point during her 36 hours at the women’s prison, it was likely she’d still be alive today.

“The sounds of Veronica’s last pleading calls for help echoed around the courtroom during the inquest, prompting me to ponder how people who heard them and had power to help did not rush to her aid,” he said.

“Much of what this inquest has revealed was confronting and traumatic.”

He referred the actions of Correct Care Australasia to the Director of Public Prosecution for investigation.

“I also find that Justice Health failed to ensure that Correct Care Australia delivered a standard of health ... and this failing causally contributed to her passing,” McGregor said.

“Veronica’s death was preventable.”

As part of his landmark findings, the coroner also called for a change to the prison system’s “inhumane” opioid detox regime which compelled people to withdraw from drugs without access to a full range of withdrawal support options.

Prison staff told an earlier inquest between 50 per cent and 90 per cent of female inmates arriving at the prison were withdrawing from drugs, the most common medical issue they encounter.

He found drug stigma impacted the quality of care Nelson received throughout her time at the prison.

Outside the hearing, Nelson’s mother, Aunty Donna Nelson, urged the government to urgently act and to name any changes to the law “Poccum’s Law” honouring the 37-year-old.

“Thank everyone who listened to my Poccum, and who have fought for her dignity and for justice. To the lawmakers, 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,” mother Aunty Donna Nelson said.

“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.

“It’s time to save our daughters. It’s time to change the law.“

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

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

Images contained in this story were released to the media with permission from the family. Crisis support run by Aboriginal and Torres Strait Islander people, contact 13YARN (13 92 76).

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