Coroner Simon McGregor's Findings into the Death in Custody of Veronica Nelson
The findings of coroner Simon McGregor into the death in custody of Veronica Nelson, a Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman, should be read carefully and regarded by the Victorian authorities with all the care and import which it is due.
The death of Veronica Nelson is of course an unspeakable tragedy, to say nothing of the injustice of it. Let me say that first of all, and let it not be thought that I mean to diminish the profundity of that tragedy when I say that though coroner McGregor's inquest is into 'only' this one death, its implications are far reaching indeed. The facts of the case are not only an isolated incident, they also serve as a case study, with important lessons about Victoria's bail laws, the treatment of indigenous people and opiate addicts in our justice system, the provision of healthcare for prisoners, and the question of what checks and balances exist for such occurrences as this and whether they're functioning as intended, as needed, or at all. We shall outline the particulars of this case, the implications for the broader issues, and the coroners findings as we go along.
Incarceration & the Bail Act
Coroner McGregor has aptly described what makes the preventable deaths of people like Veronica Nelson and so many others, who were incarcerated at the time of their death, especially heinous. That is, "the special obligation owed by the State when its authority has been exercised to assume control over a person’s life. A person in custody is not only deprived of their liberty but is deprived of the ability and resources to care for themself: in short, the State’s control over the person is nearly complete." [Emphasis mine.]
One of the more fundamental issues involved is whether we have too low a threshold for what we consider to justify or necessitate subjecting a person to absolute control in this fashion. In this case, Ms Nelson was charged with “the indictable offence of theft of fragrances from Chemist Warehouse on 9 October 2019;” and “the summary offence of failing to appear on bail at Shepparton Magistrates Court on 4 October 2019 contrary to the Bail Act.”1 McGregor wrote in his conclusion that...
“Aboriginal and Torres Strait Islander people have been calling on Governments and their institutions for decades: to stop locking up their communities for minor offences, to stop putting their children in prison, and to stop subjecting their people to systemic discrimination.”2
In addition, Ms Nelson’s case, as it was reviewed by McGregor, demonstrates a systematic failure to apply protections which exist under the Bail Act. Under s13 of that act, which contemplates the determination of ‘exceptional circumstances’ bail applications by a court, a specific exception exists granting other bail decision makers (BDMs) including police to grant bail when the accused is an Aboriginal person or a vulnerable child or adult. Although they have this power under the Bail Act, Sgt MacDonald’s evidence “was that while a custody supervisor at the MWPS for over four years, working two or three shifts per rostered week, he could not recall ever granting bail to a person who was required to demonstrate ‘exceptional circumstances.’”3
“If a court was operating, his preference was to put the accused before a court rather than make a decision about bail himself.”
Further:
“SC Gauci270 and Sgt Paynee gave similar evidence about this ‘preference’ -- or practice, having general application. Sgt Payne went so far as to say that since the Bourke Street tragedy, there was an unwritten internal policy which, in effect, meant that BDMs were less likely to grant bail.”
McGregor properly notes that “a general practice of the type described in evidence at inquest is wrong in principle and in law, as it precludes exercise of the discretion provided by s13(4)(a).” Most concerningly, “neither Sgt Payne nor SC Gauci appeared to know about the discretion.”4 The sum of these considerations McGregor spells out in no uncertain terms: the “practice of refusing bail to any person subject to the exceptional circumstances test amounts to arbitrary detention and to automatic detention, which are incompatible with sections 21(2) and 21(6) of the [Charter of Human Rights and Responsibilities] respectively.”5
We could continue describing the failures of police practices and training in this regard, but for the sake of brevity we will conclude here. Those interested can read McGregor’s detailed analysis in the section of his findings dealing with the events which took place at Melbourne West Police Station, particularly pages 86-100.
Medical Care In Victorian Prisons
The failures involved in the provision of Ms Nelson’s medical care upon her entrance to the Dame Phyllis Frost Centre (DPFC), and the broader systemic failures in the institution charged with providing this care, were and are simply profound.
Given that her cause of death is most accurately described as “complications of withdrawal from chronic opiate use and Wilkie Syndrome in the setting of malnutrition,”6 it's fair to say her case makes plain the barbarous cruelty of the Opioid Substitution Therapy Program Guidelines (OSTP Guidelines) in Victorian Prisons which mandate a six-week stabilisation period before prisoners are eligible for pharmacotherapy. As a consequence of this wholly unnecessary and unjustifiable policy, anybody entering a Victorian prison with an opioid dependence is forced to undergo an involuntary detox. They are given one or two small doses of suboxone to facilitate rapid detox but they are not stabilised on daily pharmacotherapy and the dosage they receive is not titrated based on the severity of their symptoms, as it is for civilians in the population at large.
If anybody needs a vivid illustration of how inhumane this policy is, they have only to read the detailed timeline of Ms Nelson’s last days contained in McGregor’s findings. To wit:
“Veronica arrived at the DPFC at 4:35 PM on 31 December 2019. She vomited in transit and arrived at the reception area holding a vomit bag.
...Several prison officers observed Veronica to be extremely unwell while she was in reception and the Medical Centre.
...Veronica’s reception medical assessment commenced at 5:23 PM583 and concluded at 5:36 PM; Dr Runacres’ professional consultation lasted 13 minutes. ... Three minutes later, at 5:39 PM, Veronica projectile vomited onto the floor of the Medical Centre cell in which she was placed, and again into a vomit bag.
The doctor who conducted her assessment - Dr. Runacres - left a pre-populated report largely untouched and consequently riddled with errors.7 It stated that Ms Nelson was not withdrawing from drugs and reported that she “looked generally well” and was “alert, not drowsy.”8 The nurse assisting Dr Runacres gave evidence that he made virtually no assessment of her - she couldn’t walk to a scale to be weighed, her heart and lungs weren’t examined with a stethoscope, she was not asked to lie down to be physically examined, her pupils were not checked for dilation symptomatic of opioid withdrawal, and her drug use was not specifically discussed - and that he did not move from his chair.9
Contrary to his rosy report, the assisting nurse also testified that Ms Nelson was complaining of vomiting and stomach pain, had vomit in her hair and on her clothes, was too unwell to sit upright in her chair and was instead draped over the side of it, appeared dehydrated, and was incoherent and fading in and out of consciousness.10
The nurse, RN Hills, also argued with Dr. Runacres that Ms Nelson should be taken to hospital, but the doctor considered this unnecessary.
Dr Runacres was the only person who came into contact with Ms Nelson in DPFC who maintained, and maintains, that she was not seriously unwell. There is very good reason to suppose that this is motivated by prejudice to a significant extent. In his oral testimony, he opined of CCTV footage of Ms Nelson:
“Yes, she’s vomiting and, yes, she’s withdrawing from heroin and I’m sure that’s incredibly uncomfortable, but that’s not very sick.”11
McGregor properly “[canvassed] the impact drug-use stigma had on the quality of care Veronica received while at DPFC,” and “ highlight the problematic distinction made by Dr Runacres between someone who he considers ‘sick’ and someone who presents with a history of substance use disorder and is in withdrawal.” We have on the one hand Dr Runacres, who does not consider somebody suffering from severe opioid withdrawal to be unwell; and we have on the other hand (i) the established fact, acknowledged by medical science as an institution, that opioid withdrawal is - whatever one thinks of opioid use - a form of illness, and (ii) the fact, confirmed by the coroner who performed Ms Nelson’s autopsy, that in this particular case that illness was serious enough to form a component - quite possibly the primary component - of her cause of death.
The timeline continues:
“At 5:48 PM, RPN Chisvo conducted Veronica’s initial psychiatric assessment. ... RPN Chisvo’s assessment was conducted in Veronica’s cell because she was actively vomiting.
...
Between 6:30 PM and 7:00 PM, Veronica used the intercom four times to report feeling unwell and vomiting. In the 10 minutes before 7:00 PM, Veronica vomited three times. No one came into her cell to check on her.
...
At 3:21 AM, Veronica projectile vomited into the air while lying on her back in bed.841 The vomit landed on her pillow, blankets, hair and on the floor of the cell. She used the intercom to alert PO Cole and was told there would be people in to clean up in the morning.
...
At 6:08 AM she requested cordial, explaining that she had vomited into the cup of cordial she had; she was told that no one could bring her anything.
...
At 6:37 AM, she asked for a drink and was told that she could not have a drink until more staff arrived. [She was finally given cordial at 6:53.
...
[At 8:46 she was finally escorted to a clean cell, after being left in a “vomit-ridden” cell for over 15 hours. Five minutes later, at 8:51, she projectile vomited again] She “used the intercom to inform a PO that she had ‘spewed all over [the] bed.’ Two minutes later, a CCA nurse entered the cell, inspected the blanket and left without removing the contaminated item.
...
At 9:20 AM, Veronica reported vomiting again and was told there wasn’t much the POs could do; they were waiting for “bio-clean” to come in, and for the doctor to see her.
...
[At 10:11] Veronica projectile vomited again into her blanket. Veronica used the intercom to ask, ‘when’s the doctor gonna see me?’ A PO responded, ‘it’s not an emergency, stop asking.’
...
At 11:12...Veronica projectile vomited across the cell floor. She used the intercom to inform a PO that she had ‘spewed up everywhere’ and was told ‘yep, no worries.’
...
At 11:18 AM, Veronica entered Health Holding Cell One. Health Holding Cell One has no bed, only a toilet and a bench. Veronica lay down on the bench holding a vomit bag. At 11:26 AM, she sat up and vomited into the vomit bag, and vomited again two minutes later.
...
At 11:37 AM, six minutes after receiving her metoclopramide hydrochloride injection, Veronica vomited into a vomit bag. The CCTV footage shows this was a large vomit. Veronica returned to lying down in the recovery position on the mattress after vomiting.
[She vomited again at 12:19, 1:00, 1:26, and 1:34. At some point between 4:05 and 5:10 she was approved for transfer to the Yarra Unit, meaning she was deemed fit to be kept alone and unobserved in a cell overnight. ]
...
Between 2:00 AM and just before 4:00 AM, Veronica used the intercom 11 times to complain of worsening cramps, continued vomiting and to request assistance.
...
At 3:56 AM, Veronica contacted PO Brown using the intercom and was heard wailing and calling out for her late father. She was told she needed to stop screaming because she was keeping the other prisoners awake.
[During the conversation with PO Brown at 3:58 AM, she suddenly stopped responding. Nobody checked on her. At 7:55 AM she was found dead by two prison officers during the morning count.]
This is graphic, and very disturbing, but I feel it is important. Readers who find the preceding timeline upsetting may be encouraged to know that she “wasn’t sick,” she was “just” withdrawing from opioids.
There were two main systemic failures at play here:
There were serious flaws in the communication and recording of information between and within Corrections Victoria (CV) and Correct Care Australasia (CCV).
“In Veronica’s case, CCA staff were not informed of critical features of Veronica’s clinical presentation which were known to the CV staff who received her intercom communications. The reverse was also true: CV staff were not adequately informed by CCA staff of Veronica’s condition or the degree to which she was unwell. Information was neither sought by CCA staff, nor volunteered by CV staff, and vice versa.”12
McGregor also “received extensive evidence about a poor working relationship between the two entities,” that prevented any effective working relationship; “that there were occasions on which CV staff requested assistance from a CCA nurse but were repeatedly told that the medical staff were too busy;” and “that CCA staff may find it difficult to escalate issues in the face of resistance from custodial officers817 and indicated that they fear pressing for their patient’s welfare in the face of custodial pressures.”13
There was no clear or sound policy or procedure for medically clearing a prisoner. CV, not CCA, determine prisoner placement and movement within the facility, and “there was no requirement that a medical officer positively document that a prisoner is fit to be transferred to a mainstream prison cell before that transfer occurred,” and “no formal requirement that CV staff seek confirmation from a medical officer that a prisoner is fit before moving her to a mainstream cell.”14 Essentially, Ms Nelson was transferred to a mainstream cell where she was left unobserved and alone overnight because she was considered medically fit by default.
-
The number of individual and systemic failures which lead to Ms Nelson’s preventable death is staggering. To cover everything in even a cursory fashion would take far more room than I have here. I hope, however, I have covered the most important issues involved. And I hope coroner Simon McGregor’s eminently competent report brings awareness to the travesty which is our justice system, and that in turn we may have long overdue reform.
Despite empty rhetoric to the contrary from Corrections Victoria, our euphemistically named ‘Corrections’ system is a punitive, prejudicial and unjust system, which is unfit for human habitation. It will take a great deal of work to make this system align with the most basic requirements demanded by the elementary rights and dignity of every human being.
Findings into the Death with Inquest of Veronica Nelson, Coroner Simon McGregor, Coroner’s Court of Victoria, January 30, 2023; pp. 87.
Ibid; pp. 299.
Ibid; pp. 92.
Ibid; pp. 93.
Ibid; pp. 94.
Ibid; pp. 72.
Ibid; pp. 149-152.
Ibid; pp. 152.
Ibid; pp. 155
Ibid; pp. 156.
Ibid; pp. 178.
Ibid; pp. 198.
Ibid; pp. 199.
Ibid; pp. 200.
Well put Lee.