After almost four years since the tragic passing of Heather Calgaret, following an incredibly painful and burdensome journey for her family, Coroner Sarah Gebert has delivered the findings and recommendations from the coronial inquest into Heather’s passing. Today the Coroner found that not only was Heather’s passing preventable, but that she should not have passed away in the manner that she did. These findings are another reminder of the ongoing failing of the state’s duty of care towards Aboriginal women.
Heather Calgaret was a proud Yamatji, Noongar, Wongi and Pitjantjatjara woman. She was born in Dandenong and was the middle child of her large family. She was also a mother to four beautiful children, who she loved dearly and desperately wanted to be reunited with. She was very proud of her culture and enjoyed painting and writing. Heather was the rock of her family, always helping and caring for everyone.
As a child, Heather loved school and would pretend to be a teacher. She would put all her toys in a row and pretend to teach them. When she was older and caring for nieces and nephews at home, she would run classes for them. Even in prison, Heather was surrounded by books and would write all the time.
Heather died in custody in November 2021 after being administered a high dose of buprenorphine despite not having a history of opiate use. She was found in critical condition at Dame Phyllis Frost Centre (DPFC) prison by her sister, Suzzane, who describes Heather as her “soulmate” and “other half”. Heather was only 30 years old, and was less than 10 weeks away from completing her prison sentence when she passed away.
Today the Coroner found that Heather’s prescribing doctor, Dr Nath, should not have prescribed Heather such a high dose of buprenorphine and that this dose was likely to have contributed to Heather’s respiratory depression, collapse, cardiac arrest and subsequent death. Dr Nath also had an obligation to ensure that Heather was properly observed and monitored by medical staff after receiving such a high dose of buprenorphine, which he failed to do. The inquest heard extensive evidence that this was the first time a woman at DPFC had been treated with buprenorphine without first being stabilised with sublingual suboxone strips. This was contrary to the healthcare provider’s policy at the time.
The Coroner found that the administration of this high dose of buprenorphine was inappropriate, and without it, Heather would not have passed away. The Coroner also found that if Heather had been properly observed and monitored after her buprenorphine dose, then she could have been treated appropriately, and her passing may have been prevented.
For the first time in Victoria since the toughening of parole laws, this coronial inquest examined Victoria’s parole application system; including delays, the availability of programs, and support for obtaining suitable accommodation. Heather had been eligible for parole for almost one year before she passed away. She was denied parole one month before she passed due to lack of suitable accommodation. The Coroner agreed with the expert opinions of Dr Amanda Porter, Dr Crystal McKinnon and Karen Fletcher, finding there were numerous issues with the way Heather’s parole application was handled, including Corrections Victoria’s lack of adherence to metrics, poor engagement with Heather, poor documentation practices, lack of cultural engagement, lack of availability of required treatment program, and insufficient support to identify suitable housing options to enable her release on parole.
The Coroner found that Victoria’s parole system is operating in a way that may make it impossible to give effect to some court sentences and is also inconsistent with the Department’s commitments to Aboriginal self-determination and reducing over-representation of Aboriginal and Torres Strait Islander people in Victorian custodial settings. VALS broadly supports the coroner’s recommendations around the parole application process and is willing to work with the Department as a matter of priority.
The Coroner also commented on how the removal of Heather’s youngest child, who she gave birth to in custody, was a pivotal moment in Heather’s deteriorating mental health and overall wellbeing. The Coroner found that it was a missed opportunity to support an Aboriginal woman to move forward and break the cycle of child removal. The Coroner commented on the deep trauma caused to Aboriginal women when their children are removed, which is unique trauma historically linked to colonial violence. The Coroner said Heather’s application to have her newborn child stay with her in prison was considered in a way that focused on deficits rather than strengths.
Coroner Gebert, and the expert health panel who gave evidence before the inquest, all agreed that there was a significant decline in Heather’s health while she was in prison. It was found that she did not have access to adequate culturally safe care to address this declining wellbeing, despite there being multiple opportunities for intervention. At the time that she was incarcerated, healthcare at DPFC prison was delivered by private provider CorrectCare Australasia (CCA). Heather gained over 60 kilograms while she was in prison, developed Type 2 diabetes and Obstructive Sleep Apnoea, and was prescribed seven or more medications – despite not being provided with sorely needed mental health or holistic treatment. Expert witness Professor Newman commented that in Heather’s case, medications alone were unlikely to be effective. Heather attended over 100 medical appointments throughout her time in custody, records show Heather was only seen four times by a psychiatric nurse practitioner.
Since Heather’s passing, healthcare in DPFC is now provided by a public provider as per recommendations that came out of the passing of proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman Veronica Marie Nelson, who was also incarcerated at DPFC at the same time as Heather. However, Coroner Gebert today stressed the importance of having Aboriginal Community-Controlled Health Organisations available in prison to meet the need for culturally safe and appropriate care for women.
VALS has always advocated for healthcare in prison to be of equal standard and accessibility to that available in the community. This was a key recommendation in the Royal Commission into Aboriginal Deaths in Custody over 30 years ago, yet Aboriginal and/or Torres Strait Islander people continue to face worse health outcomes than non-Aboriginal people, both in prison and in the community. According to a report in The Guardian in 2021, Aboriginal people who passed away in prison were three times more likely not to have received the required medical care compared to non-Indigenous people.
While today’s findings are damning and critical of deeply systemic issues, they yet again highlight the harsh conditions, unacceptable provisions of care and lack of holistic supports available to Aboriginal women who are in custody – and in the care of the state.
Quotes attributable to Suzzane Calgaret, Heather Calgaret’s sister and Aunty Jenny, Heather Calgaret’s mother:
“Today doesn’t necessarily bring us peace about Heather’s passing – because we already knew what had happened to her. If anything, it has just reassured us. All we have left now are memories of Heather. We have her voice on the radio, the photos that will remind us that she was here and that she was alive.
There’s that quote – ‘Don’t think about the memories too much because that will kill you faster.’ We have used this as sort of a defense mechanism; it’s too much for the heart. It doesn’t even matter what happens to the Doctor and the nurses, they still get to walk around with their life intact.
When I went into the room and tickled her, I knew something was wrong, I knew her spirit was already gone. That moment, I have to live with every day. Knowing that my sister didn’t turn her head or open her eyes to me.
We thank the Coroner, she had a lot to determine in the findings and she really studied it through and through. She did have a lot of heart, and I think she really empathised with Mum through her feelings and emotions, she had a few tears.
We’re all human at the end of the day and we need to learn to appreciate each other no matter what race, colour, shape or size.
Life really is precious.”
Quotes attributable to Amanda Dunstall, Acting CEO of VALS:
“Heather’s family have shown remarkable strength and courage throughout the past four years as they waited for answers. VALS has been proud to walk alongside them and support them, and we will continue to advocate for justice for Heather until systemic change is implemented.”
“Part of the tragedy in today’s findings is that given the Allan Labor government’s current “tough on crime approach” and abhorrent commitment to implementing regressive laws, there is no possibility that any of the coroner’s recommendations will be properly implemented.”
“Victoria’s parole process was found to be unfair to Aboriginal women, and is inconsistent with the right to equality in the Charter and the right to Aboriginal self-determination. We know that sentencing and parole considerations for Aboriginal people are of critical importance and VALS is ready to work with the Department of Corrections, alongside the Aboriginal Justice Caucus to implement these recommendations immediately, alongside the outstanding recommendations from the Royal Commission into Aboriginal Deaths in Custody, and the Yoorrook Justice Commission.”
“The system is not designed to respond to the unique needs of Aboriginal women at Dame Phyllis Frost Centre prison. Ongoing structured Lockdowns are having a significant impact on the mental health and wellbeing of women, yet the Department of Corrections continues to shirk all responsibility.”
My heart breaks for Heather and her children, especially her youngest who was removed from her as newborn while she was incarcerated. Aboriginal women have not historically, and do not currently, have access to the ‘Living with Mum program’ at DPFC. The unnecessary trauma and suffering inflicted by removing her children and not providing adequate post-natal support is completely unacceptable. This was found to be a pivotal moment in Heather’s mental health decline in custody, and it is harrowing.
Quotes attributable to Apryl Day, CEO of Dhadjowa and VALS Board Member:
“Heather’s life was precious, as are all lives of Aboriginal and Torres Strait Islander peoples, and yet we have now seen almost 600 of our people’s lives lost since the Royal Commission into Aboriginal Deaths in Custody. This is a national shame, and yet there is still no action.
“Dhadjowa was established because of the ongoing injustices inflicted on Aboriginal people and their families by the state. Today the coroner’s findings and subsequent recommendations into Heather’s passing show how the system is continuously failing its duty of care, particularly towards our women. Many of the women incarcerated at the same time as Heather knew Veronica Nelson, and have had to go through the pain of losing two of their friends, who they considered family.”
“Broken systems are continuing to fail Aboriginal families and communities, but we must bear the burden of waiting years for closure and justice which may never come. Colonial systems of oppression must be held to account so that we do not continue to see preventable deaths in custody like Heather’s.”