‘Complete, unmitigated disaster’: inquest into Veronica Nelson’s death urges overhaul of ‘discriminatory’ Victorian bail laws

<span>Photograph: Diego Fedele/AAP</span>
Photograph: Diego Fedele/AAP

A Victorian coroner has declared the state’s controversial bail laws discriminatory and a “complete, unmitigated disaster”, using landmark findings into the 2020 death in custody of First Nations woman Veronica Nelson to recommend urgent reforms.

Coroner Simon McGregor on Monday handed down the highly anticipated findings into the death of Nelson, a 37-year-old Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman who was in prison after being arrested for shoplifting and refused bail.

McGregor found Nelson received “cruel and degrading treatment” by prison staff at the Dame Phyllis Frost Centre – the state’s maximum-security women’s prison – and that her death was preventable.

He concluded that the failures of Correct Care – the private prison healthcare contractor – and Corrections Victoria to define the role of the prison’s medical centre and establish proper procedures for information sharing between staff had contributed to her death.

Correct Care was referred by the coroner to the state’s director of public prosecutions to consider whether it should be prosecuted for a breach of the health and safety act.

McGregor said the state’s bail legislation – tightened after the 2017 Bourke Street massacre – has had a “discriminatory” impact on First Nations people with “grossly disproportionate rates” remanded in custody.

Related: ‘Without dignity’: how Veronica Nelson’s death exposed cruelty of Victoria’s bail laws

As well as recommending an overhaul of bail laws, the coroner also urged the Victorian government to implement all recommendations from the 1991 royal commission into Aboriginal deaths in custody.

Nelson’s mother, Aunty Donna Nelson, called on the state government to urgently overhaul the bail laws, warning it could be “someone else’s daughter tomorrow” who might die in custody.

“Veronica did not deserve to die in such a cruel, heartless and painful way... It’s time to save our daughters, it’s time to change the law,” she told reporters.

Victoria’s attorney-general, Jaclyn Symes, acknowledged the state government needs to do “more” on bail reform.

“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,” Symes said in a statement.

The opposition’s attorney-general spokesman, Michael O’Brien, said it would work with the government on any legislative changes but warned that the catalyst of the the tightening of bail laws – the Bourke Street tragedy - should “not be forgotten”. The Victorian Greens urged the government to immediately put bail reform on the agenda when parliament resumes next week to prevent the risk of further deaths in custody.

In wide-ranging findings, McGregor said the use of handcuffs in Nelson’s arrest was “unjustified” and a “disproportionate restriction” of her human rights.

He found the police bail decision maker failed to properly consider discretion and Nelson’s vulnerability in custody as an Aboriginal woman. The legal services provided to Nelson were “inadequate”, the inquest heard.

McGregor made several adverse findings regarding the healthcare Nelson received in prison said her treatment was influenced by “drug use stigma”. He said Nelson should have been transferred to hospital at the time she arrived at the prison, concluding the ongoing failure to do so causally contributed to her death.

“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,” McGregor said.

He said the “conditions under which Veronica lived out her final days are harrowing”.

Nelson’s partner of 20 years, Percy Lovett, said the state government needed to overhaul prison healthcare, bail laws and “properly” investigate deaths in custody to ensure they were not “swept under the rug”.

“I want everyone to remember what happened to Veronica – the premier, every government minister, every prison guard, every doctor and nurse in prison, every police officer, every lawyer and every magistrate,” Lovett said in a statement read by his lawyer outside the coroner’s court.

Nelson was arrested in Melbourne at Southern Cross station on two outstanding warrants and suspicion of shoplifting on 30 December 2019. The 37-year-old was refused bail after she represented herself at a Melbourne magistrates court hearing.

Related: Pressure builds on Victoria to overhaul bail laws in response to Indigenous woman’s death on remand

Nelson was subsequently held on remand at the Dame Phyllis Frost Centre. After a 13-minute medical examination, Nelson was held in the medical ward overnight.

She was later moved to a mainstream cell. The court heard during the two nights she spent at the prison, Nelson asked staff for help on more on 49 occasions for worsening vomiting and cramps via the intercom during her 36 hours in prison.

Nelson had been withdrawing from heroin and an autopsy later found she had a rare undiagnosed gastrointestinal condition called Wilkie’s syndrome at the time of her death. She was malnourished and an autopsy later found she weighed 33kg and had a grossly dilated and distended stomach.

The Andrews government this month announced it would stop outsourcing healthcare in female prisons to for-profit companies.