On the night she died, Veronica Nelson called for help nine times over the prison intercom system between the hours of 2am and 4am.
The proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman can be heard crying in recordings.
“I need help ... badly miss, badly,” she says. In another, she calls out to her late father.
Nelson’s naked body was found cold and stiff on the floor the following morning, her hands clenched like claws.
At the time of her death on 2 January 2020, Nelson, 37, had spent three days in Melbourne’s Dame Phyllis Frost Centre – Victoria’s maximum-security women’s prison – after being arrested on suspicion of shoplifting. She was in jail after appearing in court without a lawyer and being refused bail. It was unlikely she would have been sentenced to prison if she had been convicted of the offences for which she was arrested.
During the two nights she spent in the cells Nelson asked staff for help on more than 40 occasions for worsening vomiting and cramps, the inquest heard. She begged to see a doctor. She asked for cordial and socks, because her feet were cramping.
A prison officer lied to her several times about calling for a nurse on her behalf. Veronica was told to “be quiet” and that the intercom was for “emergencies only”.
“You need to try and stop because you’re keeping the other prisoners awake. I can’t give you anything else,” an officer says.
On Monday, coroner Simon McGregor will hand down his findings into Nelson’s death, a case so shocking it has managed to cut through previous political ambivalence to force a conversation about reform of Victoria’s strict bail laws.
Despite countless previous pleas to change laws tightened in the wake of the Bourke Street massacre in 2017, it was only this week that Victoria’s attorney general, Jaclyn Symes, pledged to make amendments this year, without providing further details.
Symes conceded the 2017 changes, designed to keep repeat violent offenders out of the community, disproportionately affected First Nations people and women, who are being remanded in custody for minor offences that would not ordinarily carry a sentence of imprisonment.
“What we do know is that once people are in the justice system, it can be very difficult to get out of that spiral,” she said.
Nerita Waight, chief executive of the Victorian Aboriginal Legal Service, says Veronica’s death is the reason the state government is now considering bail reform.
“The cruelty and indifference that everyone in the criminal legal system showed to Veronica in her last days has exposed the destruction that bail laws are inflicting on individuals, their families, and their communities,” she tells Guardian Australia.
“Many people warned the government that the punitive bail laws they created in 2017 would do this and we’ve been telling them about the damage the broken bail laws have been doing over the last five years. Until the inquest into Veronica’s death in custody they have refused to even acknowledge the pain that their laws have caused.”
Amanda Porter, senior Indigenous fellow at the University of Melbourne’s law school, blames a lack of political will combined with a powerful police lobby for the slow reform on bail laws.
Despite a range of bodies calling for change, including a parliamentary inquiry, the Law Institute of Victoria, the Victorian Aboriginal Legal Service and Liberty Victoria, the police union has opposed the watering down of the laws.
The 1991 royal commission into Aboriginal deaths in custody also recommended governments revise any criteria which “inappropriately restrict” the granting of bail to Aboriginal people.
“Governments don’t listen to Aboriginal experts and Aboriginal leaders on this. They don’t listen to their own reports,” Porter says.
“Why it’s taken this tragedy for the Andrews government to move speaks to the power of the police union in Victoria and in Australia. This outweighs the overwhelming academic and policy evidence and their own royal commissions and official inquiries.”
It’s not only bail laws that are being re-examined in the wake of Nelson’s death.
Last week, the Andrews government announced it would stop outsourcing healthcare in female prisons to for-profit companies.
The coroner heard Veronica was withdrawing from heroin but also suffering from a rare, undiagnosed gastrointestinal condition called Wilkie’s Syndrome when she died. She was malnourished and an autopsy later found she weighed 33kg and had a grossly dilated and distended stomach.
Nelson’s partner of 20 years, Percy Lovett, told the court she looked unwell during her bail hearing on 31 December and on the way to Dame Phillip Frost Centre she had vomited. She arrived carrying a sick bag.
Upon arrival, Nelson was held in the medical ward overnight, where she continued to vomit and complain of cramping.
The following morning a doctor noted in Veronica’s health file that a nursing review should be performed later that afternoon. This review did not happen.
They also made a request for blood tests to examine Veronica’s electrolytes, a liver test and a full blood count. Due to the public holiday the tests could not be conducted that day.
She was then transferred to the Yarra unit, where she died.
A medical panel who gave evidence to the inquest agreed that Veronica’s life could probably have been saved if she had been sent to hospital on 1 January.
Gastroenterologist Sally Bell said the way she died was “without dignity” and “unnecessary”.
The inquest heard from prisoners and corrections staff concerned about the standard of care offered by private company Correct Care Australasia (CCA).
McGregor has the option of referring CCA to the Victorian Director of Public Prosecutions to consider whether the firm should be prosecuted for breaching the state’s health and safety act.
The Dame Phyllis Frost Centre general manager, Tracy Jones, told the court she didn’t believe its medical centre was “well equipped to look after some of more complex medical needs that our women are suffering when they come into our care.”
“I think that most of the CCA staff are there because they want to look after the women and do right by the women,” she said.
“They’re under-resourced and they’re busy and they don’t have a retention of good staff and the working conditions aren’t terrific … they probably get burnt out or become impatient or become frustrated.”
CCA’s chief medical officer, Foti Blaher, defended the company’s overall health services at the inquest, saying they met the benchmarks agreed to in its state government contract.
However, he conceded the prison wasn’t well equipped to offer substantial medical care.
The medical unit of the prison “may have the word ‘ward’ written on the front of them”, he said, but they could not be considered as similar to a hospital treatment bed.
‘A daughter, sister, partner, cousin and friend’
Lovett told the court his partner was a very strong and private person, and that race unquestionably played a role in her death.
“She wouldn’t have been crying out like that, especially to the officers, unless something was really wrong,” he said.
“They just thought she was a heroin addict and another blackfella, just wanting a quick fix. There’s another black girl crying out for drugs, she wants a quick fix. I don’t think she would’ve been treated that way if she wasn’t a blackfella.”
In the words of Sharon Lacy, the counsel assisting the coroner, during the opening of the inquest, Veronica was: “a daughter, sister, partner, cousin and friend.”
“She was loved,” she said.
“Veronica deserved to be treated with dignity in life and in passing.”