Coroner Simon McGregor, who conducted the inquest into the death in prison of Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman Veronica Nelson, said on January 30 that Victoria’s Bail Act needs to be “urgently” amended.
McGregor criticised the way Nelson was treated by police and prison staff and medical personnel employed by Correct Care Australasia (CCA), which is contracted to provide health care to prisoners in the Dame Phyllis Frost women’s prison, where Nelson died on January 2, 2020.
Nelson was arrested on December 30, 2019, accused of shoplifting and bail offences. She was handcuffed while in police custody, which the coroner found was unnecessary. He also criticised police for failing to exercise discretion and grant bail.
Nelson was not legally represented when she was brought before a magistrate, who refused bail after receiving misleading information from police.
Nelson suffered severe cramping and vomiting in the prison and called for assistance 49 times via the intercom in her cell during the 36 hours she was there. Her pleas were ignored.
McGregor found that she died as a result of a combination of health problems, including malnutrition, drug withdrawal symptoms and Wilkie’s Syndrome, a rare and previously undiagnosed disease.
McGregor said the health assessment for Nelson was inadequate and said she should have immediately been sent to hospital, as a nurse had suggested. Doctor Sean Runacres, employed by CCA, refused to do so. McGregor found that the doctor’s evidence was “unreliable”. He recorded Nelson’s weight as 40.7 kilograms. But the mortuary had recorded her weight as just 33 kg — indicating severe malnutrition.
Nelson had requested methadone to combat withdrawal symptoms, but this was refused. McGregor said the medical and other staff did not seem to think drug withdrawal was a serious medical problem and that suffering was “normal”.
McGregor said there was a “pervasive stigma” about drug use among the prison and CCA staff. He criticised them for ignoring the possibility that Nelson had other medical issues, apart from drug withdrawal.
He recommended criminal charges against CCA, under the Health and Safety Act, for its failure to create clear health and safety policies for prisoners in its care.
He also criticised Justice Health, the government body responsible for prisoners’ health, for failing to ensure that CCA carried out its responsibilities.
McGregor urged the government to implement the recommendations of the Royal Commission into Aboriginal Deaths in Custody, which said in its 1991 report that imprisonment should be “a last resort”.
The Bail Act works against this goal. It was amended in 2018 to make it harder for arrested people to get bail. McGregor described the changes as a “complete and unmitigated disaster”.
Although intended to protect the community from violent offenders, the amended law has been applied to people with no history of violence, accused of minor offences. In many cases, this has not led to a prison sentence even if the person was found guilty.
One result is that some people plead guilty just to avoid spending time in prison on remand.
Following the amendment to the Bail Act, the number of prisoners held on remand rose dramatically and the proportion of First Nations prisoners also increased.
“Between 2015 and 2019, the number of unsentenced Aboriginal and Torres Strait Islander people held in Victorian prisons tripled,” McGregor said.
The law has a “discriminatory impact on First Nations people, resulting in grossly disproportionate rates of remand in custody, the most egregious of which affect alleged offenders who are Aboriginal and Torres Strait Islander women”.
McGregor said the law is incompatible with Victoria’s Charter of Human Rights and Responsibilities.
Victorian Attorney General Jaclyn Symes has promised to “carefully consider” McGregor’s findings and recommendations. The Victorian Greens are among the many calling for urgent bail reform.