The coroner ultimately deemed both department assessments “grossly inadequate and misleading”.
For those of us who work for families in the corona jurisdiction, what is most concerning is that these assessments will influence the coroner’s decision to hold an inquest. If someone is presumed to have died of natural causes, the coroner does not need to hear witnesses, but can make determinations based on the available documents.
Correct Care and Justice knew this for sure. There is now a real public perception that they were trying to treat Nelson’s death as “natural” in order to avoid a coronal inquest. The department’s grossly inadequate conclusions show that their assessments were, at best, incompetent or, at worst, deliberately deceptive.
Whatever the truth, what is abundantly clear is that the department reviews cannot be trusted. This also chillingly raises the question of whether there have been other misleading reviews of past deaths in custody that have influenced the outcome of the coronavirus crisis.
The criminal courts readily rely on the Justice Department’s view of prison healthcare systems as equivalent to those available to people in the community. This research exposed that statement as a complete misconception.
Until the quality of health care in our prisons is dramatically increased, any First Nations person in custody can plausibly consider their time in custody a possible death sentence.
Aboriginal deaths in custody are becoming more common across Australia. Since 1991, our federal and state governments have adopted the expert recommendations of the Royal Commission into Aboriginal Deaths in Custodyabout why so many indigenous people died indoors, and what the government and society could do about it.
However, most of these recommendations have not been implemented. Instead, there has been a proliferation of conflicting policies and laws, such as Victoria’s infamous bail laws. These strict bail laws, introduced in 2018 in response to the Bourke Street massacre, have meant that Victorian prisons have grown with many people found not guilty of a crime. The majority of women held at the Dame Phyllis Frost Center have not been convicted.
The 1991 royal commission also stated that governments should “review any criteria which improperly restrict the granting of bail to Aboriginal people”. Nelson’s inquest showed that the police could have granted bail, but that discretion was not exercised. Instead, Nelson appeared in court unrepresented by the lawyer who had been briefed to represent her, and she had to plead for herself in order to pass Australia’s highest bail test (the “exceptional circumstances” test, formerly reserved for the most egregious offences, such as terrorism and murder).
And so Nelson, like far too many other Aboriginal women, was sent to the Dame Phyllis for a petty shoplifting and died within 36 hours of getting there.
What Aunt Donna Nelson, Veronica Nelson’s mother, demands is simple: responsibility. She is relieved to know – for the safety of others and to prevent future deaths in custody – that Correct Care has now lost its contract to provide health care to Dame Phyllis and that there is bipartisan support for bail reform – for the Poccum’s law, named after Veronica’s nickname.
We should also consider amending the coroner’s law so that any death of an Aboriginal in custody would be investigated through a mandatory inquest, without exemption. None of the cover-ups would have come to light had the Coroners Court not decided to investigate Nelson’s death through an inquest.
As for the Justice Department, if public confidence in its so-called independent review mechanisms is to be restored, those who signed Nelson’s reviews must be removed from office. An urgent review must also be carried out by an external auditor, or even another royal commission, to determine whether misleading reports have previously influenced a coroner’s decision not to hold an inquest.
It is deeply disturbing that if Veronica Nelson had not communicated her calls for help through an intercom where those calls were recorded, her death could have been covered up as “natural causes”. Her death would not have been investigated by the coroner and the story of her death would be as the department and Correct Care wanted us all to believe – that there was nothing to see here.
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