One year after Inquest findings, more must be done to honour Veronica Nelson

Veronica Nelson was a proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman who should still be alive today. Veronica passed away in the Dame Phyllis Frost Centre Prison on 2 January 2020. The Coroner found that Veronica’s death was preventable and made extensive recommendations to ensure no-one suffers the same torturous treatment as Veronica did.

Today marks one year since the Coroner’s findings were delivered. Since then, important reforms have been implemented such as putting healthcare in women’s prisons back in the hands of public healthcare providers and making the bail laws less punitive. These are important changes that would have saved Veronica’s life. Changes that certainly would not have occurred without the strength and determination of Veronica’s loved ones and their fight for justice.

However, the recommendations of the Coroner have not yet been fully implemented and the Victorian Government must do more to ensure the reforms called for by Veronica’s family and the Coroner get done so that we can be assured that in a week, in a month, or even a year – we are not talking about another preventable death in Victoria’s prisons.

Three of the key areas for reform from the Coroner’s findings were:

  • prison healthcare
  • bail law; and
  • reviews into deaths in custody.

The Coroner recommended wholesale reforms of the prison healthcare system in Victoria, including independent scrutiny of prison healthcare and real qualitative changes on the ground. However, years after Veronica’s death, the Government still hasn’t implemented these crucial changes. Veronica’s Inquest also revealed the harms and inequality of a privatised prison healthcare system. While it is important that the Victorian Government has put healthcare in women’s prisons back in the hands of public healthcare providers, healthcare in men’s should be delivered by public healthcare providers as all lives in our prison system should be valued. As recommended by the Coroner, and called for by Veronica’s family, Aboriginal health services should be funded to deliver culturally appropriate healthcare services in all of Victoria’s prisons. We urge the Victorian Government to commit to this process and establish a plan for transitioning to a better model of healthcare in all prisons as this will stem the tide of preventable deaths in custody.

The Victorian Government passed bail laws in late 2023 that should reduce the number of people held on remand in Victoria if implemented properly. These laws also strengthen the protections for Aboriginal people due to the historical and ongoing over policing and overincarceration of our people. However, these reforms not only fell well short of Poccum’s Law – the reforms that Veronica’s family asked for, but also what the Coroner recommended and what expert reviews have recommended for two decades. The bail reforms did include a statutory review due to take place in 2026, and we urge the Victorian Government to begin the work to implement Poccum’s Law in full within this term of Parliament.

Alarmingly, several government reviews into Veronica’s passing found that there had been no failings in the way Veronica had been treated. These reviews were clearly inadequate and would have covered up the significant systemic failings aired at the Coronial Inquest if Veronica’s family had not kept asking questions. VALS is deeply concerned that this reform is not being progressed properly by the Victorian Government. Reviews of deaths in custody need to be rigorous and appropriately transparent, and reviews into Aboriginal deaths in custody must be culturally appropriate – this is only just and fair. VALS believes that the Victorian Government has and continues to fail on this area of reform.

Quotes from Uncle Percy Lovett, Veronica’s partner:

“The Government needs to make big changes to stop this from happening again.

The Government needs to fix prison healthcare. These companies who just want to make profits off us shouldn’t be involved in healthcare in prisons. Blackfullas should be able to get healthcare from the Aboriginal Health Services. They should have the same doctors and nurses as in the community.

The bail laws have got to be changed, they just have to. Veronica shouldn’t have been in jail, she should have got bail. No one should be in prison for shoplifting.

The government needs to properly investigate deaths in custody and not let anyone sweep them under the rug again. They need to listen to families and stop ignoring us.”

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

“Veronica’s passing was a preventable tragedy. She was deeply loved by her family and an important part of her community. Her passing was avoidable, and she should still be alive today.”

“The Coronial Inquest into Veronica’s passing was a landmark case and one of the most important Coronial Inquests in Victoria’s history. It is a blueprint for transforming the entire carceral system. The Victorian Government cannot do half the job and move on – that isn’t justice, that isn’t closing a gap, that isn’t fair. VALS will certainly not move on and will continue to advocate and make noise until the government fully delivers.”

“VALS will continue to amplify the advocacy of Veronica’s family and Aboriginal communities across Victoria to create a just and fair legal system – one deserving of our communities and all Victorians.”

“Every Victorian should know Veronica’s story and the stories of all those that have needlessly died in custody. Victorians must keep the pressure on politicians to make sure no one else is treated the same way ever again.”

Quotes Attributable to Sarah Schwartz, Principal Managing Lawyer, Wirraway, Victorian Aboriginal Legal Service:

“So far, the Victorian Government has only made piecemeal reforms to prison healthcare policies and has not implemented the on-the-ground changes, or independent and rigorous scrutiny of prison healthcare, which we need to prevent further deaths. Despite being on notice for years about major failings in the prison healthcare system, the Government is dragging its feet on critical changes and people continue to die in custody and suffer because of neglectful prison healthcare.”

“We still speak to women in prison who say that nothing has changed since Veronica died. They still struggle to access the medical care that they need and are treated in cruel and degrading ways when they seek help.”

“People like Veronica who pose no risk to anyone’s safety, and may not even receive a sentence of imprisonment, can still be refused bail and held for long periods in prison on remand. We still speak to children and adults who are in prison on remand even when they would be unlikely to receive a term of imprisonment.”

“Inquests into deaths in custody are still not mandatory in Victoria, and when they do occur, are often years after a person has died. Unlike in the public healthcare system, families are not consulted or kept informed about internal government reviews into their loved one’s passings. Families often have to wait years to find out crucial information about how their loved ones have died. This is cruel and exacerbates a family’s grief and trauma.”

“So far, no individual or organisation has faced any disciplinary action or criminal prosecution for their involvement in Veronica’s passing.”


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