Thread by @dhadjowa

Day 12 of the Coronial inquest into the death in custody of Veronica Nelson. This morning, Leanne Reid, Supervisor of the Med Unit will continue her evidence. Karen Heath and Michelle Reeve, both prison guards at DPFC, are also scheduled to give evidence #JusticeForVeronicaNelson

Follow this thread for updates. If you can, come down to the Coroner's Court to support the family, or listen in online via the below link.

#JusticeForVeronicaNelson

csvic.webex.com/mw3300/mywebex…

Counsel Assisting continues questioning. There is a back and forth between CA and Reid about the lack of med clearance docs, which resulted in Veronica being transferred to the Yarra Unit

Reid gives evidence that a convo between corrections and medical staff must have occurred

CA asks Reid to try and recall how she received the info that Veronica was well enough to be moved to the Yarra Unit from the Med Unit.

Reid says she rarely speaks with nurses and doctors, and suggests that this info would have been relayed to Ms French, a senior prison guard

CA suggests to the witness that there is a 'gaping hole' in the communication process around medical clearances, which result in women being transferred out of reception into the units of the prison.

Reid agrees with this

#JusticeForVeronicaNelson

We hear evidence that an Aboriginal Wellbeing Officers was not contacted when Veronica arrived at DPFC, and that had an Aboriginal Wellbeing Officers been contacted, they could have potentially communicated concerns about moving Veronica to the Yarra Unit

We hear evidence that there was a sign on Veronica's cell in the Yarra Unit which said, “new reception, do not unlock”.

Reid is asked why this sign was there and gives evidence that this was likely because Veronica was a new reception.

When asked by Counsel Assisting what checks were outstanding for Veronica which lead to this sign being on the door Reid gives evidence that there there may not have been any, and that the sign is generic

#JusticeForVeronicaNelson

The witness is asked about what situation satisfies a Code Black being called in DPFC. The court has heard evidence that Veronica was crying and screaming out and stating that she was in enormous pain. Reid is asked if this should satisfy the criteria of a code black.

Reid: Yes

Stella Gold, Counsel for Aunty Donna, Veronicas Mum, is now asking qs.

Reid gives evidence that there is often "a battle" between prison staff and medical staff, when a woman is unwell. Reid states there is often push back from medical staff

#JusticeForVeronicaNelson

Yesterday Reid described the CCTV and audio clips of Veronica in the med unit in the early hours of Jan 1 as 'confronting' and 'below the standard' she expected. Counsel ask if this was surprising.

Reid states that it wasn’t surprising as she knows who the officers on duty were

When asked why this isn't surprising to her, Reid gives evidence that she has had conversations with these officers in the past about how they speak to each other, to other staff, to Prisoners and how they conduct themselves.

#JusticeForVeronicaNelson

Describing how prison guards spoke to Veronica via the intercom when she was held in the medical unit, Reid states "I think it is disgusting behaviour and nobody should be treated or spoken to like that"

#JusticeForVeronicaNelson

The witness is told that 1 thing the Coroner is considering is if Veronica experienced prejudices due to her Aboriginality, drug use, or criminal history

Reid gives evidence that these would be questions that she hope these prison guards would ask themselves and answer honestly

Reid is asked about the level of obs she would expect of Veronica given that she had buzzed for help 14 times over night in the Yarra Unit.

Reid gives evidence that if someone was using the intercom throughout most of the night, she would
have called senior staff

Reid is asked about the formal debrief that was held after Veronica died in custody at DPFC.

Q: When Veronica passed, to your knowledge, was there a debrief about her passing?

R: I don't know. If there was I was not involved.

#JusticeForVeronicaNelson

Q: I want to suggest you would have had something pretty important to contribute
R: Yes
Q: Do you know why you weren't invited?
R: No
Q: You would have been able to elaborate/discuss the difficulties with respect to communication between prison officers and medical staff?
R: Yes

Counsel for Aunty Donna: the minutes [from the debrief] say, "I've been around multiple deaths and we try to identify gaps and what could have been done better. After reviewing the incident I can't see much that could have been improved." Do you agree with that conclusion?

R: No

Q: And if you'd been there at the debrief would have you expressed that opinion?

R: Yes.

#JusticeForVeronicaNelson

Q: You've made some comments about...the intercom communications between Veronica and correctional staff and you describe them as disgusting. Do you think that they were in line with Correction Victoria's policies?

R: No

Q: What about the failure of correction staff to to check on Veronica for hours when she was screaming and asking for help when she was in the Yarra Unit?

R: No

#JusticeForVeronicaNelson

Michael Stanton, Counsel for Jill Prior, from the Law and Advocacy Centre is now asking qs

Q: I want to ask you about your evidence in relation to what you described as disgusting behaviour by the 3 officers over the intercom...there is a lack of respect for Veronica?

R: Yes

Q: And a failure to treat [Veronica] with dignity?
R: Yes
Q: You gave evidence you escalated your concerns about the manner of communication by custody officers with Prisoners...How have you done that?
R: 1 on 1 convos...theres been times...there would have been reports written

Q: Does it surprise you that in the reviews of Veronica's passing...there is no criticism of the manner of communication between COs and Veronica?
R: Are you asking me personally or professionally?
Q: From your experience relat[ing] to that issue
R: No, it doesn't surprise me

Supervisor Reid is released as a witness.

The next witness called is Karen Heath. Heath has been working at DPFC for 19 years. Heath was working as an Acting Senior Prison Officer, the second most senior person in the prison, on the night of Jan 1, from 10pm-6am on Jan 2.

Heath gives evidence she was not asked to write a statement about the night that Veronica died until 12 months later.

We hear that on the night of Veronica's death only Heath and the Security Supervisor had keys to open traps and cell doors in DPFC.

#JusticeForVeronicaNelson

CA asks Heath about when cells are open over night.

H: If a nurse needed to do observations
CA: Any other circumstances?
H: Mainly if somebody was unwell. If we had to call a code… generally we don’t open during night unless an emergency

#JusticeForVeronicaNelson

Heath is asked about escorting the nurse on duty, Anthena George, to the Yarra Unit to provide Panadol to Veronica.

CA: At this stage, what information did you have about Veronica?

H: The nurse advised me that Ms Nelson was withdrawing

CA: Did she indicate that [Veronica] was unwell?
H: No, she just said she was withdrawing
CA: Were you aware Veronica had been moved out of med unit that day?
H: No
CA: Did Nurse George appear concerned about Veronica?
H: No

CA: You attend upon the cell in which Veronica is located. And you opened up the trap?
H: Thats correct.

In Heath's statement she describes Veronica's room as 'disheveled'. Clothing over floor. The shower is on and Veronica is on her bed.

Heath states that when she opened the trap so the nurse could give her with Panadol, Veronica appeared to have trouble moving and looked unstable. Heath states that Veronica wasn't wearing any clothing and grabbed a blanket to cover herself, but was having trouble holding it up.

CA: What observations did you make of Veronica's physical presentation?
H: She just didn't look well...to me it was more unwell than what I'd normally say that somebody that had been withdrawing...When she came to the trap she put her hand through the trap and [it] was cramped

CA: You’ve described her hand. Was that cramped like a claw?
H: Yes
CA: Is it fair to say that the state of Veronica’s presentation to you gave you cause for concern?
H: Yes
#JusticeForVeronicaNelson

CA: Did the nurse Anthena George make any remarks to you in relation to Veronica's hand or presentation?
H: No
CA: Did anybody at this point suggest that the cell should be unlocked so that Veronica could be examined?
H: No
#JusticeForVeronicaNelson

Heath is asked about Nurse George's interaction with Veronica when the trap was open to the cell Veronica was in.

CA: Did she ask Veronica about her hand?
H: No
CA: Any instruction on medication?
H: No
CA: Did she ask you to open the cell door to conduct an assessment?
H: No

Heath gives evidence that she raised her concern for Veronica's health with Nurse George.

CA: When did you raise this?
H: At the door
CA: And what was the response?
H: Nothing

CA: Leaving Veronica's cell at 1:30am..what did you understand to be the plan in relation to Veronica’s health?
H: I knew she would be assessed the following morning. I thought meds (Panadol) would get her through the night
CA: Did you make any inquiries about that?
H: No

Counsel Assisting asks Heath about the effects of calling a Code Black overnight.

Heath: Officers on ground would respond to unit...We would open the cell if required
CA: When is Code Black called to your knowledge?
Heath: To any medical emergency
#JusticeForVeronicaNelson

CA: What do you consider to be a medical emergency?
H: I’d be going off what a nurse said to me.. I was just advised [Veronica] was withdrawing. That was all I knew.
CA: Do you have power for a women to be transferred to hospital?
H: That would generally be the nurses call

CA: So you as the Senior Acting Prison Officer on duty have no power to make a decision that a woman needs to be transported to hospital?

Heath: No

#JusticeForVeronicaNelson

CA: You’ve observed this unusual feature of her hand cramped into claw, you are the 2nd most senior person in prison...1 of only 2 people who have keys...Why is there no escalation in relation to Veronica’s health when you attend the cell?

Heath: I can't answer that..

CA: You have a duty of care to Veronica?
H: Yes
CA: You've made an obs of her being very unwell...Why is there no discussion about... escalation...in relation to Veronica’s health?
H: I took the nurse over, she gave meds. As far as I could see that was all that was required

CA: Why did you not consider that her presentation might require further observations or checks from the prison officers throughout the rest of the morning?
Heath: I think that's a call for the nurse to make, not me, I'm not a medical professional.
#JusticeForVeronicaNelson

CA: Don’t you have a duty of care to Veronica...that extends beyond what the nurse would say to you?
H: I followed that duty by taking the nurse over to give her meds
CA: Were you made aware Veronica continued buzzing for help after you delivered meds?
H: I was not

CA: Were you made aware Veronica continued buzzing expressing she has vomited up her meds?
H: I was not
CA: That Veronica continued buzzing up complaining of cramps?
H: I was not
CA: That other women in the cells had been buzzing up requesting help for Veronica?
H: No

CA: In your view, speaking as an experienced Prison officer, what should have happened for Veronica after you left her at 1:30am?

Heath: As far as I was concerned, she had her medication and she'd gone to sleep

#JusticeForVeronicaNelson

CA: So in your experience as a Senior Prison Officer, following your departure at 1:30am, nothing further should have bene done for Veronica?

Heath: Not from me, no.

#JusticeForVeronicaNelson

Mr Woods, Counsel For Percy Lovett, Veronica's Partner is not asking qs

We hear evidence that in Heath's statement she says “I saw Ms Nelson through the widow and I thought she looked very unwell...I said to the nurse...it was lucky she was in custody, because she is so unwell”

Q: Would you agree that the buzzer was all Veronica had at her disposal?
H: That correct
Q: You'd accept that there was a complete failure to help Veronica when she needed it on the night of the 2nd Jan, do you agree?
H: Yes

Counsel for Percy Lovett: Given evidence that Veronica's usual practice was to go and seek medical help when she needed it, as it turns out she was actually tragically unlucky rather than lucky for being in custody, do you agree?

Heath: Yes

#JusticeForVeronicaNelson

Stella Gold, Counsel for Aunty Donna, Veronica's Mum is now asking qs.

Q: After Veronica passed a debrief was held on 16 Jan, did you attend?
H: No, I wasn’t asked
Q: Your name is on the list
H: I never went to a debrief

#JusticeForVeronicaNelson

Q: You are listed as an attendee...some comments you made seem to be minuted, does that cause you to remember?

H: Possibly

#JusticeForVeronicaNelson

Q: You were asked a lot of questions about why you didn’t call an ambulance, you said it was a matter for nurse. Is that right? Is that is where you see your responsibility ends and the nurses responsibility starts?

Heath:...I’m not medically trained

#JusticeForVeronicaNelson

Q: In evidence you said you found [Veronica's] hands 'alarming'
H: Her hand was cramped up
Q: You use the word alarming. Do you now change your evidence?
H: No. Look, it was upsetting to see her hand like that

#JusticeForVeronicaNelson

Q: Did you think the nurse had conducted a med assessment through the trap?
H: I imagine she would have looked at her chart
Q: Why do you think the nurse was making a med assessment if all she was doing was looking through a trap?
H: I would imagine that she..didn't have concerns

Q: When you formed the view the nurse was applying medical expertise and judgment, it was because the nurse was dispensing medication (Panadol)?

Heath: Yes

#JusticeForVeronicaNelson

Counsel for Aunty Donna: No doubt you would understand any med assessment is better conducted with an open door?
H: If she had of asked me to open the door I would have got permission to open the door
Q: Did you suggest the door be opened?
H: No

#JusticeForVeronicaNelson

Karen Heath is released a witness.

Michelle Reeve is called to give evidence. Reeve has worked as a Prison Guard at DPFC for 10 years. Reeve was conducting the morning count in the Yarra Unit on Jan 2, the day that Veronica was found dead in her cell

#JusticeForVeronicaNelson

CA asks Reeve if she could hear anything at 7:59am when she approached cell 40, the cell that Veronica was held in.

R: I could hear the shower running

We heard evidence earlier today from CO Heath that the shower was running in Veronica's cell at 1:30am earlier that morning

CA: What did you do?
R: Looked through observation window...Thinking they’re in shower...Knocked on window of the cell...then looked to left expecting the prisoner to be in shower…couldn’t see anyone in shower… diverted my eyes down, and saw the prisoner laying on the floor

CA: Once you have identified that Veronica is laying in cell floor what did you do?
R: Acknowledged my other officer very briefly and then called a Code Black
CA: What was the purpose of the Code Black?
R: Medical attention
#JusticeForVeronicaNelson

Reeve gives evidence that as she was calling a Code Black, Prison Guard Pettigrove opened the cell

CA: Once the cell door was open, what observations did you make of Veronica's cell?

Reeve: It was wet, it had flooded a bit…everything appeared wet

#JusticeForVeronicaNelson

1/2

CA: Once you got inside cell...did you approach Veronica?
R: Straight away
CA: What did you do?
R: I knelt down beside her...I felt initially for a pulse...I put my hand here to feel if there was any breathing or any breath coming out...

2/2

Reeve cont: I asked my offsider Mr. Pettigrove I said what's the lady's name? And he told me it's Veronica. I gently tried to rouse her something like "Veronica Veronica. Can you hear me? Veronica? Are you okay?"... Then again...I felt her neck. I couldn't feel the pulse.

CA: Did you form the view that she had passed?

Reeve: Yes, I did.

#JusticeForVeronicaNelson

CA shows the witness CCTV from the point the Code Black was called.

CA: Was there any CPR attempted inside the cell?

Reeve: No there was not. Not by myself or Mr Pettigrove

#JusticeForVeronicaNelson

In the CCTV shown to the court there are approx 10 corrections staff standing in the corridor next to the cell that Veronica is in

The witness is asked about her understanding of the roles that need to be performed by attending prison officers

#JusticeForVeronicaNelson

CA: There are 3 prison officers against the back wall...Do you understand what their roles are at this time?

R: They are what we call operational support. They escort people that perhaps aren't always at the prison.

#JusticeForVeronicaNelson

CA: In this instance, what roles might they be required for?

R: Just to assist and if need, provide extra support, get blankets if we need.

CA: Are you able to answer on this particular occasion whether they were tasked with anything?

R: I can't be sure no

CA: Is it the case that not everybody attending has any has a particular role?

R: ...I would agree

CA: Are you aware of the cultural significance for Aboriginal and Torres Strait Islanders of respecting the privacy of a woman's body even in passing?

R: We have had training

CA: Was there any discussions about the need to respect that privacy during these interactions?
R: Not that I heard.
CA: Is there any discussion at this point about moving the men outside of the room?
R: Not that I was aware of
#JusticeForVeronicaNelson

CA: You’ve indicated that you heard someone in medical asking that someone call an ambulance. To your knowledge when was an ambulance called?
R: I’m not sure
CA: Med staff who we saw came in on that clip would have been the ones to make the call to call an ambulance?
R: Yes

The court is played 3 calls between 000 and DPFC.

The first call is made from the supervisors office in Yarra Unit. It was not made by someone who had access to Veronica.

The 000 call-taker asks repeatedly to get a phone next to the patient so they can give CPR instructions

CA: Do you have any knowledge as to why somebody removed from the scene is the person who contacts the emergency providers?

Reeve: My knowledge is limited around those areas

#JusticeForVeronicaNelson

CA: Have you received any training of how to respond to an Aboriginal person who has passed?

Reeve: No, I have not

#JusticeForVeronicaNelson

Andrew Woods, Counsel for Percy Lovett, Veronica's Partner is now asking questions.

Q: I take it you understand that there are particular cultural sensitivities of an Aboriginal woman who has passed?
R: Yes
Q: You have received no training?
R: No
#JusticeForVeronicaNelson

Q: One of the issues that Mr Lovett is keen for the Coroner to consider is the viewing and treatment of Veronica’s body after it was found that she had passed. You said to your knowledge, no one moved Veronica's body, is that correct?
R: That's correct
#JusticeForVeronicaNelson

Q: We’ve heard evidence from a prisoner who was proximate that she heard one of the screws say “no don’t move her”... its possible isn't it, that Veronica's body was moved and you simply didn’t see it, correct?
R: Correct
#JusticeForVeronicaNelson

The witness is released and court adjourns until 10am tomorrow morning.

Tomorrow registered nurse Anthena George will be called to give evidence.

Please come down to the Vic Coroners Court and support Veronica's family tomorrow if you can.

#JusticeForVeronicaNelson

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