Warning to Aboriginal and Torres Strait Islander readers: This story contains images and references to a deceased person.
The Victorian Aboriginal Legal Service has marked the one-year anniversary of the findings on the death of Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman Veronica Nelson to urge more reforms to the justice system.
VALS chief executive, Nerita Waight, said Ms Nelson was a deeply loved member of the community, whose death was an "avoidable tragedy."
"The Coronial Inquest into Veronica's passing was a landmark case and one of the most important Coronial Inquests in Victoria's history," the Yorta Yorta and Narrandjeri justice leader said.
"It is a blueprint for transforming the entire carceral system. The Victorian Government cannot do half the job and move on – that isn't justice, that isn't closing a gap, that isn't fair."
Ms Nelson died alone in a cell at Dame Phyllis Frost Centre in January 2020 after being arrested for shoplifting and a failure to appear on bail. She died from a rare gastrointestinal condition – known as Wilkie's syndrome - along with malnutrition and opiate withdrawal, and her death was found by the coroner to have been preventable.
The findings led to widespread calls for bail reform in Victoria after the coroner labelled them a "complete, unmitigated disaster," with her family leading the charge to enact "Poccum's law" in honour of her.
Ms Nelson's partner, Uncle Percy Lovett, said on Tuesday the government still needed to implement "big changes" to prevent further deaths.
"The bail laws have got to be changed, they just have to," he said.
"Veronica shouldn't have been in jail; she should have got bail. No one should be in prison for shoplifting. They need to listen to families and stop ignoring us."
Uncle Percy said healthcare in prisons needed to be fixed, with companies "who just want to make profits" no longer being allowed to work with prisoners.
"Blackfullas should be able to get healthcare from the Aboriginal Health Services," he said.
"They should have the same doctors and nurses as in the community."
VALS said the coroner recommended wholesale changes to prison healthcare, bail law andmreviews into deaths in custody, only some of which had been enacted.
"Reviews of deaths in custody need to be rigorous and appropriately transparent, and reviews into Aboriginal deaths in custody must be culturally appropriate – this is only just and fair.
"VALS believes that the Victorian Government has and continues to fail on this area of reform."
The Victorian Government overhauled bail laws last year, which VALS commended, saying they "should reduce the number of people held on remand in Victoria if implemented properly." However, VALS noted that the new laws "fell well short" of the reforms Ms Nelson's family, the coroner and expert reviews had recommended.
VALS principal managing lawyer Sarah Schwartz said they speak to incarcerated women who say nothing has changed in the wake of Ms Nelson's death.
"They still struggle to access the medical care that they need and are treated in cruel and degrading ways when they seek help," Ms Schwartz said.
"Despite being on notice for years about major failings in the prison healthcare system, the Government is dragging its feet on critical changes and people continue to die in custody and suffer because of neglectful prison healthcare.
Ms Schwartz said unlike in the public healthcare system, families are not consulted or kept informed about internal government reviews into their loved one's passing in cases involving a death in custody. Ms Nelson's family had campaigned tirelessly to have a coronial inquest.
"Families often have to wait years to find out crucial information about how their loved ones have died," Ms Schwartz said.
"This is cruel and exacerbates a family's grief and trauma.
"So far, no individual or organisation has faced any disciplinary action or criminal prosecution for their involvement in Veronica's passing."