Prison Guards Contravened Remandee’s Human Rights, Coroner Finds

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Victorian Coroner Simon McGregor has ruled found Veronica Nelson’s human rights were repeatedly breached from the time of her arrest on 30 December 2019, to her death a few days later, on 2 January 2020, at women’s prison Dame Phyllis Frost Centre. 

Ms Nelson was found unresponsive in her cell, in a pool of her own vomit. 

Yorta Yorta woman Veronica Nelson was arrested on suspected shoplifting charges and alleged breaches of bail.

She died in custody just three days later. 

Calls for help fall on deaf ears

The coronial inquest following Ms Nelson’s death heard evidence that was particularly confronting, including that she made 49 calls for help on the intercom during her 36 hours in prison. 

The official cause of Ms Nelson’s death was identified as Wilkie’s Syndrome. She was withdrawing from heroin and was also malnourished, but despite her pain, Ms Nelson never once displayed anger or aggression – in the recordings played to the inquest she was very polite.


In delivering his final report this week, Coroner McGregor remarked, ”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 them did not rush to her aid,” McGregor said. 

He also noted that Ms Nelson was “separated from her family, community, culture and Country at the time of her passing in a devastating and demoralising circumstance.”

The failings of those who owed Ms Nelson a duty of care while she was in custody have been well documented, including that prison officer, Tracey Brown, the senior staff member on night shift in the prison unit where Veronica died, didn’t check her cell after she became unresponsive on her final intercom call. 

The same night, the facility nurse Atheana George spent hours watching a movie, apparently unaware Ms Nelson was dying in her cell.

Changes to healthcare delivery in Victorian prisons 

The Victorian Government recently announced it would stop outsourcing all health care provided to women’s correctional centres across the state of Victoria. Female inmates at Dame Phyllis Frost Centre, have long complained about the standards of care, reporting that even obtaining something as simple as a panadol can be notoriously difficult. 

If there is to be any kind of silver lining here, in the findings of yet another tragic and preventable death of an indigenous person in custody, it is that Coroner McGregor also called for a sweeping overhaul of Victoria’s Bail Act. 

Mr McGregor noted that changes to the Act made in 2018 are not only incompatible with the Charter of Human Rights but also have a discriminatory impact on First Nations people resulting in grossly disproportionate rates of indigenous people and Torres Strait Islander people on remand in custody.

The 2018 changes to Victoria’s Bail Act were made in the wake of the Bourke Street killings – some might describe them as a knee-jerk reaction by the Victorian Government as it faced enormous pressure to placate a devastated and angry Melbourne community. 

Six people died and 27 others were injured when James Gargasoulas deliberately drove a stolen car into Bourke St Mall in a ‘drug-fuelled, psychotic, delusional’ act. He had been released on bail several days earlier. He is now serving life in prison. 

Harsh bail laws

Changes made to Victoria’s bail laws have meant that people facing minor offences are being put in the same category for the purpose of bail applications as those facing far more serious charges – including aggravated assault, sexual offences and even murder.

This means that those who are accused of low-level offences but have contravened their bail conditions in the past are being routinely kept behind bars pending the finalisation of their cases, despite the fact they do not pose a danger to the community or a flight risk. The change has contributed to the number of Aboriginal women being held behind bars nearly doubling since 2018.

And while changes to the Bail Act are something positive to focus on, we must not lose sight of the fact that Ms Nelson’s pleas for help were repeatedly ignored by the only people who could help her. People who were being employed to oversee her wellbeing. 

The fact in the face of such damning evidence of lack of care, that prison officer Tracey Brown could be ‘proud’ Ms Brown told the coronial Inquest that she was ‘proud’ of the way Ms Nelson was treated suggests a serious disconnect between what prison staff consider to be their duty, and what community expectations are. This is something that really needs to be addressed if we are to stop needless deaths in custody. 

Ms Nelson’s long-term partner, Percy Lovett, has recently commenced a wrongful death lawsuit over the alleged negligence of prison officers. Documents have been made in the  Supreme Court of Victoria, stating a claim against five parties – the State of Victoria, Corrections Victoria, the Department of Justice and Community Safety, Justice Health’s executive director and contractor Correct Care Australasia.

Dying without dignity 

Mr Lovett is seeking aggravated and exemplary damages, and a court declaration that the five defendants breached the Charter of Human Rights and Responsibilities Act 2008.

The Coroner is also in agreement. Speaking of the prison system, Coroner McGregor said: “A person in custody is not only deprived of their liberty [but also] deprived of the ability and resources to care for themselves. In short, the state’s control over the person is nearly complete.” 

He also noted that “the assumption that it is normal for patients withdrawing at Dame Phyllis to experience a level of suffering normalised such suffering and results in a desensitisation of both corrections and corrections care staff,” and “the conditions under which Veronica lived out her final days are harrowing”.

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Sonia Hickey

Sonia Hickey is a freelance writer, magazine journalist, and owner of 'Woman with Words'. She has a strong interest in social justice and is a member of the Sydney Criminal Lawyers® content team. Sonia is the winner of the Mondaq Thought Leadership Awards, Spring 2022.

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