‘I should’ve done more’: Nurse watched movie as Veronica Nelson called for help

Warning: This story contains graphic content and the name and images of a deceased Indigenous person.

As Veronica Nelson lay critically ill in a jail cell during her final hours, the prison nurse in charge of her medical care sat in the health centre nearby watching a film.

Nelson, an Indigenous inmate being held on remand, was suffering from severe heroin withdrawals and an undiagnosed medical condition when she repeatedly buzzed the intercom, at times wailing, to ask for help.

Nurse Atheana George arrives at the Coroners Court of Victoria on Thursday.Credit: Justin McManus

“Stop … you’re keeping other prisoners awake,” one prison officer replied.

On Thursday, registered nurse Atheana George told a coronial inquest into Nelson’s death that she’d failed to perform proper medical assessments, check the new arrival’s electronic medical records or intervene in her medical care.

These, George conceded, were “missed opportunities” that could have saved Nelson’s life before she was found in a fetal position on the floor of her cell, cold to the touch.

“I should’ve done more to [help] her,” she said.

Nelson had arrived at the prison on remand on New Year’s Eve in 2019 and spent a night in the medical unit – due to severe heroin withdrawal – before being moved to the general population Yarra Unit the following day. She was found dead 24 hours later.

The coroner heard attending paramedics believed she had been “passed for quite some time”.

On Thursday, the inquest heard that George, who had worked as a nurse for 13 years, was the only nurse working the night shift at Dame Phyllis Frost Centre on both nights Nelson was there.

Stationed in the medical centre, she was responsible for the care of new arrivals and those being held in the prison’s general population units.

George told the coroner she had no interactions with Nelson during the new arrival’s first night, but peered through her glass window on her way to the bathroom and saw her sleeping.

Video footage played to the inquest showed on the following night – the night of Nelson’s death – George was again working alone when she attended the inmate’s Yarra Unit cell at about 1.30am to provide her with Paracetamol and anti-nausea medication.

She spent less than a minute peering through a trap door – with three prison guards nearby – before unclenching the inmate’s cramped fingers to give her the pills.

George said she didn’t ask for the cell door to be unlocked because she was scared of the officer in charge but conceded she should have done so.

“I should have checked her. I should have asked the officer to open the door,” she said.

“Veronica was so polite and calm. I thought she was OK at that stage.”

Over the next two hours, George was alerted again to more of Nelson’s calls for help over the intercom to prison officers. But security footage showed the nurse did not return to her cell and spent hours watching a film on a prison computer.

She said she told prison staff they should bring the 37-year-old back to the medical cells, but Nelson declined.

“You watch a movie over hours, don’t you?” counsel assisting the coroner Sharon Lacy asked.

“Yes,” George replied.

The nurse left the prison at 6.30am without making any medical notes about Nelson’s health, before later returning to do so after learning the inmate had died. George told the coroner she forgot to do this earlier.

“I don’t know what happened to me on that day,” she said.

When pressed on her actions, the nurse agreed that failing to check Nelson’s electronic medical file was an oversight she could not explain but maintained she wasn’t made aware of the number of intercom calls Nelson made to prison guards.

Coroner Simon McGregor is examining Nelson’s death as part of a five-week inquest after it was revealed she had unsuccessfully applied for bail on her own, without legal representation, before being held in custody at Dame Phyllis Frost Centre on allegations of shoplifting.

The inquest previously heard Nelson was one of 505 First Nations people to have died in custody since findings from the Royal Commission into Aboriginal Deaths in Custody were handed down in 1991.

George had previously asked that the court suppress her name, but McGregor ruled against it.

The inquest continues.

Images and audio contained in this story were released to the media with permission from the family. For 24/7 crisis support run by Aboriginal and Torres Strait Islander people, contact 13YARN (13 92 76).

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