Heather Calgaret: Coronial Inquest begins 

The coronial inquest into the death in custody of Heather Calgaret will begin on Monday 29 April 2024 at the Coroner’s Court of Victoria and is scheduled to run for four weeks.  

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 children. She loved 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 at Sunshine Hospital in November 2021 after being found in a critical condition at Dame Phyllis Frost Centre Prison by her sister, Suzzane. She was only 31 years old.  

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. If she had been granted parole, she would not have been in prison. In a first for Victoria since the toughening of parole laws, the coronial inquest will examine Victoria’s parole application system, including delays, the availability of programs, and support for obtaining suitable accommodation.   

The inquest will also consider the quality and cultural appropriateness of healthcare provided to Heather at Dame Phyllis Frost Centre, including whether an 8mg dose of Buprenorphine administered the day prior to her being found unconscious contributed to her passing. As was recently identified in a ground-breaking report from the Victorian Ombudsman, prison healthcare is continually failing to meet the needs of Aboriginal people with evidence showing they suffer worse and more complex health outcomes than non-Aboriginal people in prison and in the community.  

It is expected that the Coroner will hear from a number of critical witnesses including members of Heather’s family, the women who shared a unit with Heather at Dame Phyllis Frost prison, the doctor who administered the dose of Buprenorphine, and expert witnesses on Victoria’s broken parole system including Dr Amanda Porter, Dr Crystal McKinnon and Karen Fletcher.   

Quotes Attributable to Aunty Jenny Calgaret, Heather Calgaret’s mother: 

“Heather had a kind heart, a kind soul and she was very caring. Heather was like an old mother hen type person. As she got older, she was the one who helped me with looking after the kids and family. Heather was my rock in the family and I knew I could depend on her. During the holidays, we would sit and watch movies and cuddle and laugh and muck around. We were really close and would do everything together.   

“When Heather was in prison I was trying to help her manage her health, but it’s very difficult to provide that support from the outside. I have so many questions about why Heather’s health deteriorated so badly in prison when she didn’t really have health problems before that. I don’t think the prison gave her the healthcare she deserved.” 

“It don’t think Heather was given a fair chance at parole. I got my house specifically so Heather and Suzzane could stay here when they got parole. I had it set up right and we were all so excited to be together again. I don’t know why they thought my house was unsuitable, only Heather’s brother and I were at home and there is nothing wrong with my house. I still don’t understand what they expected, did they expected me to have a mansion?” 

“If Heather had gotten parole, she would be alive today. The whole family would have supported her. There’s no way she would have died if she was living with us.” 

Quotes Attributable to Suzzane Calgaret, Heather Calgaret’s sister: 

“My sister was my soulmate and my best friend. She gave me so much love and she gave our whole family so much love. She was kind and caring.” 

“The parole board, the prison staff, and the nurses and doctors all act like they’re all on power trips. They’re supposed to help people get rehabilitated and never have to come back to prison, not treat them like dirt and ensure they never leave alive.” 

“People need to understand that life is precious. Heather’s life was precious – it is a blessing and a gift to us. It shouldn’t have been gambled with by prison systems and by parole boards. It shouldn’t have been taken away from her like that.” 

My nieces and nephews won’t get to grow up with their mum. If Heather got proper healthcare, if she was allowed out on parole, her children would get to grow up with their mum. How is all this fair on them?” 

“We need to know the truth about how they treated Heather and why she died. Nothing will ever bring my sister back. But we want to make sure that what happened to Heather never happens again to anyone else. No-one should ever have to feel the way me and mum do. I am suffering so much without her”.   

Quotes Attributable to Apryl Day, Daughter of Tanya Day and Executive Officer of the Dhadjowa Foundation: 

“Heather’s unjust denial of parole in 2021 is one of too many examples of the failures in Victoria’s legal system. Had the parole system prioritised community care over punishment, Heather would still be here with her family today.”  

“The Allan Government must recognise its role in denying Heather and her family the opportunity for reunite and take immediate action to prevent further deaths. It’s unacceptable for families to bear the burden of advocacy while grieving their loved ones.” 

“The Victorian government must commit to putting an end to Aboriginal deaths in custody and the systemic racism and discrimination targeting our community. It’s long overdue for decisive action to ensure justice, accountability and healing for our families.” 

Quotes Attributable to Sarah Schwartz, Principal Managing Lawyer, Wirraway Police and Prison Accountability Practice, Victorian Aboriginal Legal Service: 

“I hope that Premier Jacinta Allan is personally watching this Inquest and commits to taking real action to prevent more deaths like Heather’s” 

“No family should have to face their loved one dying in a prison cell, no child should lose their mother to a cruel prison system. I admire the strength of Heather’s family, who deserve answers and justice through this process.” 

“Heather’s Inquest comes two years after the Inquest into the passing of Veronica Nelson. Despite piecemeal reforms, Victoria’s prison healthcare system is still failing Aboriginal women.” 

“Victoria’s parole system is a disaster. Reactionary legislation introduced by successive governments has created an unfair and punitive system which disproportionately impacts Aboriginal and Torres Strait Islander women like Heather. The parole system in Victoria makes it harder for people to be supported in the community, discriminates against people who don’t have access to housing, and steals away people’s lives. The parole system is making communities less safe.” 

Quotes Attributable to Nerita Waight, CEO of the Victorian Aboriginal Legal Service: 

“VALS is proud to be supporting Heather Calgaret’s family. The system failed Heather, like it has failed so many of our people before her. The Allan government should have been forced to act a long time ago, and if they had, Ms Calgaret may still be here with us today. Instead, her family is fighting to make Victoria better, safer for our community. Their strength is inspiring, and VALS will be in their corner for as long as they need us.  

“There’s been a spike in Aboriginal deaths in custody in Victoria in recent years due to poor prison healthcare and unfair processes like Victoria’s parole system. At least 560 Aboriginal and Torres Strait Islander people have died in custody since the Royal Commission into Aboriginal Deaths in Custody – that’s one death every three weeks. This is unacceptable. Prison sentences should not be a death sentence for Aboriginal people.” 

“Housing is a fundamental human right. The Allan Government should expand transitional housing support programs like VALS’ Baggarook program and increase housing supply for vulnerable Victorians. These are critical measures that will improve parole rates and ensure that people can be supported within their communities and stay out of the prison system, and remain connected to community and culture.”  


Over the last two decades, Victorian Governments have made the parole system increasingly punitive and difficult. This has had a disproportionate impact on Aboriginal and Torres Strait Islander people, and particularly Aboriginal and Torres Strait Islander women like Heather. VALS has concerns that many people who are eligible for parole are being denied because of lack of housing availability, lack of transparency in the way the Adult Parole Board operates (particularly due to the lack of natural justice principles), lack of rehabilitation programs in prison, excessive delays, lack of access to automatic parole, and the parole revocation scheme.  

VALS represents the families of several Aboriginal families whose loved ones have died in custody over the last 5 years. Almost all of these cases include issues relating to substandard healthcare provided in prisons. In January 2023, The Victorian Government announced private healthcare providers would be replaced by public healthcare services in Victoria’s women’s prisons in response to scathing findings in the Coronial Inquest into the Passing of Veronica Nelson – a proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman who also passed at Dame Phyllis Frost Centre Prison less than two years before Heather.  

According to an analysis by The Guardian Australia in 2021, Aboriginal people who died in custody were three times as likely to not receive all required medical care compared to non-Indigenous people. Aboriginal women were less likely to have received appropriate medical care prior to their death compared to Aboriginal men. Statistics like this should have forced governments into action long ago – Ms Calgaret may still be here if they took this crisis seriously. 


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