Victorian government faces potential record payout

McGregor told his inquest on Monday that the bail laws that jailed Nelson were a “complete and unmitigated disaster”.

Victoria’s bail laws were passed in 2018 in response to the Bourke Street massacre, which was carried out by a violent offender who was on bail at the time.

Veronica Nelson.

Opposition Leader John Pesutto said the Coalition would work with the government in a bipartisan way to improve the justice system, but called on Labor to introduce legislation next week.

“We are back in parliament next week, and there is no reason why we cannot begin the early steps to address the problems that led to this tragic loss of life,” Pesutto said.

The coroner’s report into Nelson’s death paved the way for changes in the way Indigenous Victorians were treated by the criminal justice system.

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

Commenting on the government’s failure to implement the recommendations of the Royal Commission into Aboriginal Deaths in Custody, McGregor said if it had been done 30 years ago, Nelson would still be alive today.

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

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“Veronica was loved and respected by those who knew her. Yet while alone in a cell at the Dame Phyllis Frost Centre, Veronica passed away after pleading for help for several of the last hours of her life,” McGregor said.

“She was found the next morning on the floor of a cell in a prison built on the land of the Wurundjeri and Bunurong people.

“That Veronica was separated from her family, community, culture and country at the time of her death is a devastating and demoralizing circumstance.”

The prime minister said on Tuesday the government would seek advice on all the coroners’ recommendations and expected to overhaul processes and work cultures, not just the law.

“The death of Veronica Nelson is a terrible tragedy, and one that will bring significant reform and change,” Andrews said.

“The greatest and most respectful thing we can do through sympathy and grief and empathy with the Nelson family is to go ahead and do the hard work of making these changes and reforms and also making sure that our systems and processes work as they should when an inmate is sick, they get health care.

“When a prisoner is an Indigenous Victorian, then those provisions written specifically for Indigenous Victorians are properly applied. The list goes on.”

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

Over the next two days, she made 49 calls for help over the prison intercom as 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 undiagnosed Wilkie syndrome, a rare but potentially life-threatening gastrointestinal condition.

McGregor referred the actions of Correct Care Australasia to the Director of Public Prosecutions for investigation.

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

“Veronica’s death was preventable.”

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

“We know we need to do more with regard to criminal justice reform, including bail reform, and that work continues,” she said.

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

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