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Victorian coroner refers prison contractor to prosecutors over death in custody of Veronica Nelson

Giovanni Torre -

The Victorian coroner has brought down the findings in the inquest into the death in custody of Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman Veronica Nelson, and has referred government prison contractor Correct Care to prosecutors after finding the company may have breached occupational health and safety laws over their treatment of Ms Nelson.

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

He described the conditions in which she spent her final days as “harrowing”.

Coroner McGregor also slammed the state’s bail system on Monday morning, describing the current laws are a "complete and unmitigated disaster" and backing sweeping reforms.

Ms Nelson died alone in her cell in a Melbourne prison on January 2, 2020, after being arrested over alleged shoplifting-related offences.

The 37-year-old represented herself in court and was refused bail just days before her death.

During the inquest, CCTV footage showed her struggling to walk around her cell, with severe cramping in her legs and feet.

Footage had also shown Ms Nelson projectile vomiting multiple times onto the floor and into her blankets. She used the cell intercom to call for help 49 times in 36 hours.

The coroner said the sounds of Veronica’s pleading calls for help echoed around the courtroom prompting him to ponder how the people who heard them and had the power to help her did not rush to her aid, send her to hospital or simply open the door for cell to check on her.

"Veronica was loved and respected by those that knew her, yet Veronica, while alone in her cell at the Dame Phyllis Frost centre, passed away after begging for assistance for several of the last hours of her life," he said.

"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 separate from her family, community, culture and country at the time of her passing is a devastating and demoralising circumstance."

The coroner said Ms Nelson’s “journey through the criminal justice system” did not include contact with “a single Aboriginal person” employed to provide culturally appropriate support.

Mr McGregor noted that person in custody “is not only deprived of their liberty, but deprived of the ability and resources to care for themselves.”

“In short, the state's control over the person is nearly complete.” The coroner noted that the death an Aboriginal person occurs in custody “occurs on the continuum of the problematic relationship between the Australian criminal justice system and First Nations people”.

Mr McGregor pointed out that the Royal Commission into Aboriginal Deaths in Custody a years-long thorough investigation, authoritatively linked Aboriginal over-representation in custody “to the continuing consequences of the colonisation of Australia and it's Indigenous people”.

“The significance of access to bail in the over-representation of Aboriginal people in custody was also identified by (the Royal Commission) has continued to feature more reformed reviews conducted by federal the Victorian government,” he said.

The coroner noted that Victoria had, in fact, gone backwards since the Royal Commission in regards to bail laws, with statutory amendments to Bail Act, enacted in 2017 and 2018, a “complete and unmitigated disaster”.

"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," he said.

Mr McGregor noted the testimony of Ms Nelson’s partner, Percy Lovett, who said she was always a respectful and well mannered person when dealing with those in authority.

The coroner also said that in his view the use of handcuffs on Ms Nelson when originally arrested was not reasonably necessary and an unjustified and disproportionate restriction of her human rights.

In 2022 the five-week inquest into the death of Ms Nelson heard the coroner heard multiple systems failed Veronica in the days leading up to her death.

The state’s bail laws force people accused of minor, non-violent crimes to clear significant hurdles in order to be granted bail.

Mr McGregor said the impact of the bail law changes in 2017-18 had been "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 even if proven".

In 2022 a panel of justice experts gave evidence to the coroner unanimously urging the state’s Bail Act be reformed immediately.

Mr McGregor said he endorsed proposals to amend the Bail Act "urgently".

Victorian Attorney-General Jaclyn Symes said the death of the death of Veronica Nelson "was a tragedy – nothing less".

"Our thoughts are with Ms Nelson’s family and friends today. We thank the coroner for his work and will carefully consider his findings and recommendations.

"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."

A state government spokesperson said changes are being made to address the over-representation of Aboriginal people in the justice system, in addition to investments have also focused on early intervention – to prevent crime and reduce reoffending.

The government has committed to bringing health care contracts in women’s prisons under state control.

From 1 July 2023, the contract for providing primary health services at Tarrengower Prison and Dame Phyllis Frost Centre will transition from Correct Care Australasia to Dhelkaya (Castlemaine) Health and Western Health respectively.


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