Thread by @dhadjowa

Day 13 of the Coronial inquest into the death in custody of Veronica Nelson. Today Registered Nurse Anthea George will give evidence. George was the last medical staff member to have contact with Veronica before she died on the morning of Jan 2 2020 #JusticeForVeronicaNelson

Nurse George saw Veronica briefly when she handed her Panadol through the trap of the cell in the Yarra Unit at 1:30am on Jan 2. Prison guard Health has given evidence that at this point Veronica's hands were cramped into a claw and George did voice concerns for Veronica's health

We encourage you to come down to the Coroner's Court and support the family by sitting on the inquest today. You can also join online using the below link, or follow for updates here.
csvic.webex.com/mw3300/mywebex…

#JusticeForVeronicaNelson

Registered Athena George is called as a witness and Counsel Assisting begins questioning the witness.

CA asks George about the statement she has provided to the Coroner's Court about her interactions with Veronica in the early hours of the morning on Jan 2

At the start of her evidence Reg Nurse Athena George was granted a Cert of Privilege by the Coroner for evidence given at the inquest. Counsel Assisting reminds the witness that this Cert does not provide protection from the offence of Perjury

#JusticeForVeronicaNelson

CA informs the witness that the weight of evidence before the court from numerous people describes Veronica as unwell in a number of different ways at the time that Veronica was at DPFC from 31 Dec 2019 until she died on 2 Jan 2020

#JusticeForVeronicaNelson

CA: In relation to your statement...do you see there you describe your interactions with Veronica in the early hours of that morning on Jan 2..."Ms Nelson did not appear unwell."...Is there anything you would like to change, before you acknowledge it is true and correct?
G: No

Registered Nurse Athena George was working the night shift at DFPC on 31 Dec 2019 and 1 Jan 2020. On both nights she was the only nurse on duty, which we hear is standard practice. There is no Doctor on Duty overnight, however there is a Doctor on call #JusticeForVeronicaNelson

CA begins questioning the witness about the evening of 31 Dec, the night that Veronica was held in the Medical Unit at DPFC because Nurse Hills and Supervisor Reid both had concerns for Veronica's health.

#JusticeForVeronicaNelson

CA: On 31 Dec did you return to Med Centre about 11:30pm?
G: Yes
CA: Did you see Ms Nelson in Ward 2?
G: Yes
CA: Did you speak to her at all?
G: No
CA: Did you look in through the glass and check on her?
G: No
CA: Did you have anything at all to do with Veronica that night?
G: No

CA: You said you knew [Veronica] was staying in medical unit that night?
George: Yes
CA: Did you know that corrections supervisor Leanne Reid had deemed her not well enough to move to Yarra Unit?
George: Yes
#JusticeForVeronicaNelson

Nurse George is asked about the handover she received when she began her shift on the Med Unit on Dec 31

CA: The Psychiatric nurse Bester Chisvo said she told you that Veronica was unwell
G: I think I didn’t see her on that night
CA: Can you not remember?
G: I can’t remember

There is a comment "Nelson to stay in Medical O/N vomiting ++" in the Nurse Handover Book.

CA asks George what this means.
G: That means she is unwell
CA: What did you take the ++ to mean after the word vomiting
G: Withdrawing from drugs or symptom of withdrawal

CA: Does the ++ indicate anything about amount [Veronica] is vomiting?
G: That means she is vomiting heavily
CA: So you were aware overnight that Veronica had been vomiting heavily?
G: Not on my night shift, no
CA: You were aware she had been vomiting during the day?
G: Yes

CA: Did you at any stage pull up the JCare file in relation to Veronica?
G: No
CA: Would you usually do that for a prisoner who is held in the medical unit for being unwell?
G: Yes

George states she should have checked Veronica's JCare file the night she was held in the med unit

CA asks George why she didn't check Veronica's JCare File

G: She didn’t make any complaints...There was nothing to do, so I didn’t check it
CA: Is there an expectation...to check the files of someone....staying in med overnight...whether or not they complain?
G: Yes

George states that unless a patient complains she will not assess them, but will "keep an eye on them"

CA: [on the night Veronica was in Ward 2] you just had a look as you were walking past to go to the toilet?
G: Yes
CA: You didn't stop to see if she was breathing?
G: No

CA asks George about tasks she would usually undertake on night shift as the Registered Nurse on duty.

CA: So the rest of the time other than distributing your medications after around 9-9:30pm or so. Are you effectively sitting at the nurse's station?

George: Yes

George gives evidence that tasks on the night shift can vary depending in Code Blacks are called in different Units of the prison.

CA: According to notes, would you except you were spending some time sitting at the nurses stations [on Dec 31]?

George: Yes

CA: Were you aware [Veronica] made contact with officers during the night?
G: I don’t know
CA: So will you hear a buzz?
G: I can hear sometimes, If I am at the nurses station I can hear the buzzer
CA: So if the speaker is on you can hear the patient?
G: Yes, if the speaker is on

CA: We know that Veronica did contact the officer overnight
George: Yes
CA: Did you hear that convo?
George: I can’t remember
#JusticeForVeronicaNelson

CA plays CCTV of Veronica vomiting in a projectile fashion at 3:22am in the med unit

When asked what this tells the Nurse about Veronica's health, George responds that sometimes when people are withdrawing they will be sick. She says for the first couple of days this is normal

CA: Even if these symptoms are normal...that prisoners who are withdrawing from heroin can suffer from, do you view that as being unwell? Are they treated as unwell? Or simply withdrawing?
G: Withdrawing
CA: As opposed to being sick and needing treatment?
G: Yep

CA is now asking about George's night shift that began on Jan 1. Veronica had been transferred from the Med Unit to the Yarra Unit

CA: Are you provided any handover info about Veronica?
G: No
CA: Do you make any inquiries?
G: So they will just say “they are moved to Yarra Unit”

CA plays the witness CCTV of when George receives a phone call from Officer Brown from the Yarra unit at 1:28am

CA asks if Brown told her that Veronica had said she was withdrawing heavily and complaining of legs, feet, and hand cramps

G: She said Veronica complained of cramps

CA: Did she also tell you Veronica was withdrawing heavily?
G: No
CA: Did you have any understanding Veronica had been vomiting?
G: No
#JusticeForVeronicaNelson

Nurse George is asked if she reviewed Veronica's JCare file, the med assessment undertaken by the Dr or the opiate withdrawal scale form prior to going to the Yarra Unit to see Veronica

George gives evidence that she did not review any of these docs.

#JusticeForVeronicaNelson

CA: Do you say now you should have looked at these documents before you went to see her?
G: Yes
CA: Is there any reason why you didn't look at those documents?
G: I don't know

#JusticeForVeronicaNelson

CA: Did you have a sense of what [Veronica's] baseline condition had been in the period prior?
G: I knew was that she was withdrawing for heroin
CA: Did you know she was Aboriginal?
G: Yes
CA: How did you know?
G: ...there is a photograph of her
#JusticeForVeronicaNelson

CA shows the witness CCTV of when she arrived at the Yarra unit around 1:30am on Jan 2 and is escorted to cell 40, where Veronica is being held.

In Nurse George's statement she says that when the senior officer opened the trap she could see Veronica Nelson lying on the bed

CA: Did you see yourself indicating something with your hand?
G: I asked her to come to the trap
CA: She took some time to come to the trap?
G: No, when i called her and said "Veronica, can you come to the trap” ...she came to the trap without any problem

The court hears the interaction between Nurse George and Veronica last for about 1 min 40 secs. CA asks qs referring to the CCTV

CA: See there, you are touching her hand. Whats going on with her hands?
G: When I touched it she opened it completely. It wasn't closed or anything

CA: The Senior Officer gave evidence that she observed Veronica's hand cramped like a claw...Do you disagree with that?
G: Yes
CA: [She] also said it was alarming to her, and confirmed to her that Veronica was really struggling
G: No, she was not
#JusticeForVeronicaNelson

CA: Heath has also said she didn't hear you saying anything to Veronica
G: No, I asked her how she was feeling and what were her complaints
CA: Is it your position that there was nothing about that presentation...that concerned you she might be unwell?
G: No...she was looking ok

CA: Is it your understanding that the cramping can be a symptom of dehydration?
G: Yes.
CA: It can be an indicator of electrolyte imbalance?
G: Sometimes
#JusticeForVeronicaNelson

CA: So you were aware that she had a history of vomiting
G: Yes
CA: That she was withdrawing?
G: Yes
CA: You're now seeing signs of cramping?
G: Yes
CA: Her hand in the position...was indicative of the cramping...described to you by Brown?
G: I didn't think that at the time

CA assisting asks a number of qs about why Nurse George did not think that Veronica's hand was a sign of
severe cramping.

George gives evidence that in the past she has not seen cramps in the hand when other Prisoners have been withdrawing from heroin.

CA: Do you think that severe cramping in the legs, sign of cramping in the hand and info you had about her vomiting in the day prior ought to suggest that she might be suffering from dehydration or electrolyte imbalance?
G: No...I just treated her with the symptoms I saw

CA: Thats because you didn't check her file to get the other information, isn't it? And if you had got that other info, you would have had a lot more info about how much she'd been vomiting since she'd arrived at DPFC?
G: Yes
#JusticeForVeronicaNelson

CA: Now from this point you had a number of options, didn't you?
George: Yes
CA: You could have asked the senior officer to unlock the door so that you could have undertaken an assessment of her?
George: Yes

CA: If you had undertaken an assessment of her, would you have been able to learn more info about how unwell she was?
G: Yes, but when I checked her through the trap...she was talking to me. When they are severely withdrawing, they will not talk to you
#JusticeForVeronicaNelson

CA: Were you looking and assessing Veronica through the lens of someone who was withdrawing from heroin?
G: Yes...When she came to the trap she was really lovely and she was talking to me, so I thought she was okay
CA: Because she was polite to you?
G: No, the appearance of her

Counsel Assisting asks the witness if only being able to see Veronica through the trap on the cell door limited Nurse George's ability to assess her.

Nurse George states that when she was kneeling down, she was able to see Veronica's whole body.

#JusticeForVeronicaNelson

CA: Do you say that you were not limited in any way by looking through a trap, rather than being face to face with [Veronica]?

Nurse George: Face to face would be better, but I can do a general quick assessment through the trap

#JusticeForVeronicaNelson

CA: You say [Veronica] presented differently to someone who you would expect is withdrawing from drugs. Did that not cause you to want to examine her further?
G: Yes
CA: Why didn't you?
G: The way she was presented to me, according to my nursing knowledge, she was looking okay

CA: You can't really do anything other than have a visual of [Veronica] in what appeared to be about 1 min..through a hole, is that right?
G: Yes.
CA: Do you accept that falls far short of the nursing obs or exam that you should have taken from her?
G: I should have checked her

CA plays the witness audio of Veronica, from 10 mins prior to when Nurse George spoke to Veronica through the trap. Veronica sounds very distressed and can be heard saying "I need help. I need help badly."

CA: Do you agree she doesn't sound very calm there does she?
G: No

CA: Was the way that [Veronica] spoke to you in any way consistent with that audio?
G: No
CA: So do you say she was presenting completely differently to that when you are on site?
G: Yes
#JusticeForVeronicaNelson

CA: Senior Officer Heath has said that it appeared to take [Veronica] a lot of effort to get out of bed and come across to the trap. Do you agree with that?
Nurse George: No.
#JusticeForVeronicaNelson

CA: Were you imagining you were looking at someone whose only ailment might be withdrawal from heroin. Is that an assumption that you made?
G: I look at how a person appears to me...When I asked her to come to the trap she came without any problem she had a steady gait

CA: There have been other officers... who described [Veronica] as being unsteady on her feet or falling over... But you say that's not consistent with what you observed. When you say she has a steady gait...
G: She was standing in an upright position and was not wobbling

CA: You weren't in a position through a trap to undertake a Glasgow Coma score assessment were you?
G: I can do a quick look at Glasgow Coma Scale...
CA: You say you can sufficiently do an assessment to provide a Glasgow Coma score through a trap in less than a minute?
G: Yes

CA: Did Officer Brown inform you that Veronica had been screaming out from her cell over a period of hours prior to your interaction with her?
G: No.
CA: When you were at the trap...did you speak with the other officers about Veronica?
G: No

CA: Senior Officer Heath has said that she told you that she thought that [Veronica] was very unwell.
G: No.
CA: Are you saying that conversation didn't happen?
G: Yes
#JusticeForVeronicaNelson

CA: Do you accept you should have asked for the cell door to be open?
G: Yes
CA: Do you accept you should have undertaken a formal nursing assessment of [Veronica]?
G: Yes
CA: Do you accept you should have undertaken all nursing observations including of her vital signs?
G: Yes

CA: Do you accept that your failure to do so amounted to a missed opportunity to assess Veronica for signs of deterioration in her health?
G: Yes
CA: Do you accept that you might then have discovered how sick she really was?
G: Yes
#JusticeForVeronicaNelson

CA: Do you accept you might have realised how sick [Veronica] was to get her emergency med treatment?
G: Yes
CA: Do you accept if that had been done, her death might have been prevented?
G: Yes
CA: You could have gotten her into hospital & that could have saved her life?
G: Yes

CA plays CCTV to the witness of Nurse George sitting at her desk in the nurses station after she has visited Veronica in the Yarra Unit.

CA: There's something on the screen there that's playing on your computer screen?
G: Yes
CA: Is that a movie playing?
G: Yes

CA: You are watching a movie aren't you and you are watching a movie over hours.. We've just cut little clips of this but we could play a very very long period of time of you sitting there watching a screen moving that appears to be a movie.

#JusticeForVeronicaNelson

Following Nurse George's visit to Yarra Unit Veronica's uses the intercom 6 more times

CA: You receive a second call from officer Brown, don't you?
G: Yes

George gives evidence that she told Brown she could not given Veronica any more tablets, despite Veronica vomiting them up

CA: What if you know that a patient's thrown it up?
G: I can call the Doctor and ask to get an order for injection maxolon
CA: So you could have done that, couldn't you?
G: Yeah
CA: And you didn't do that?
G: No

G: If [Veronica's] throwing up continuously she can't hold anything orally...She needs to be on IV fluids
CA: At this point should you have arranged for her to go to the hospital & get IV fluids?
G: Not at this stage
CA: Should you have gone back to assess her?
G: Yes

CA: Did it occur to you to do that?
G: No.
CA: Did you just not want to do that or not?
G: I didn't go.
CA: In terms of what you were doing instead of going back to the unit there was nothing more pressing...that stopped you going back to the unit now?
G: No

The court is played the final audio clip of Veronica using the intercom to ask for help. Veronica is screaming out for help. Officer Brown tells Veronica her only option is to go to the Med Unit. The court is also played CCTV of the phone call between Brown and Nurse George

CA: At that point, you could have gone back and assessed [Veronica]?
G: Yes, but the way Ms Brown was talking to me, the only thing she said she was screaming and she's disturbing other prisoner and keeping them awake. She didn't tell me that she was screaming this loud

George gives evidence that her plan was for Veronica to be transferred to the medical unit so she could undertake an assessment of her.

CA: Did you agitate for that plan for her to come to the medical centre?
G: I was waiting for her to come to the medical centre

CA: The question was did you agitate for her to come to the medical centre?
G: I told Officer Brown to arrange for her to come to the medical centre
CA: Did you direct her to do that?
G: Yep

CA: You do not say in your statement that you direct [Brown] to bring Veronica over to the med centre, do you?
G: ..I told her to contact the operational manager.. and haver her brought to the med centre
CA: You're saying it was a direction?
G: Yes

CA: Is your evidence you gave the direction for her to be brought over, but you didn't follow through?
G: I made another phone call and asked...why she's not coming to the med centre
CA: You should have followed through with that direction to have her brought to medical?
G: Yes

CA: Had you done that you might have been able to get her the help she needed?
G: Yes.
CA: That was another opportunity. That was missed, wasn't it?
G: Yes
#JusticeForVeronicaNelson

Aunty Donna's counsel Stella Gold begins their questions. She starts with questions about Nurse George's understanding of her role as a nurse in the prison system.

SG- Prisoners who you provide health care to are entitled, you'd understand, to healthcare equivalent of that they could get in the public health system.
G- Yes
SG- And similarly, your professional obligations ... don't change because they're in the custodial setting.
G- Yes

Sg- You'd accept wouldn't you that there was a power imbalance between you and Veronica
G -Yes
SG- And you were the nurse, she was the prisoner and she was relying on you to provide her healthcare services.
G- Yes
#JusticeForVeronicaNelson

Aunty Donna's counsel turns to questions relating to Nurse George's relationship with Officer Heath, who George has said she was scared of in her earlier evidence to the Court.

You said in your evidence today that you were scared of asking officer Heath to open the door and this is a note of what was taken, I will be corrected if it's wrong.

SG- "'Because of her [Officer Heath] I was so scared of asking her to open the door on that day...So I was so scared to ask her to open the trap. If it was another officer, I would have asked her to open the trap.' You remember giving that evidence?"
G- Yes

SG -And the reason you would have asked that other officer to open the trap is you needed to trap to be open. So you could provide any level of medical care to Veronica.
Yes.
And the reason you say you didn't ask Officer Heath to open the trap is because you were scared of her

[When they are saying trap, they are actually meaning the door - the door needed to be opened. The trap is the small opening on the bottom of the door.]

SG - So what I want to say is you being scared or prison officer hate meant that you couldn't provide any medical care to Veronica that night.
Nurse George - No.

The Court was shown footage of Nurse George watching movies whilst Veronica needed medical attention - she gave evidence that she watches movies bc the medical centre of prison was "quiet" and "creepy" - "Sometimes I'll watch the movie because it's really quiet or something."

SG - Would you accept there are lots of things that you didn't do with respect to providing care to Veronica.
Nurse George - Yes

SG - Do you see those women who are staying overnight as your patients?
G - Not particularly.
SG - Do you not see yourself as having any proactive role in providing the medical care?
G - It depends upon their condition

Sg - Okay, so what you're saying is because there are long periods, possibly hours with as nurse in the nurse's station overnight, is it your evidence that the medical centre is not an appropriate place for a prisoner who is sick?
George - Yes.

Nurse George - "But actually there is if somebody's sick or anything they need, according to the CC [Correct Care] policy, they need to go to the hospital."
#JusticeForVeronicaNelson

Aunty Donna's counsel to Nurse George: "Your evidence is on the night of the 31st of December, you had no contact with her whatsoever, even though she was one of only two prisoners in the medical centre."
#JusticeForVeronicaNelson

Aunty Donna's counsel to Nurse George: "What if someone's so unwell they can't complain. I mean, Veronica, did complain and did ask for help. So she's not in this category. But what about someone who's so unwell, they can't ask for help?"
#JusticeForVeronicaNelson

SG - Do you accept that you provided no nursing care to Veronica at all on the night of the 31st?
G - Yes
SG - On the 2nd night...you were there for about 1 minute and 40 seconds and you've looked through the trap for certainly less than one minute you'd agree with that?
G- Yes

SG - You think she was looking OK?
Nurse George- Yep.
SG- So in fairness, I'm going to put this to you because it's going to be submitted by Aunty Donna to the Coroner - we'll submit that either, you're lying now, or your practice that night as a nurse was totally incompetent.

Andrew Woods representing Percy Lovett begins his questions.
-What was your previous experience with Prison Officer Heath that made you frightened of her?
Nurse George - "Because she never treated me in a good way first of all..
#JusticeForVeronicaNelson

..Because then one day.. I don't know how to say it.. But you know, whenever if I asked for a help or anything, she always treated me really badly..."
#JusticeForVeronicaNelson

AW - You're aware or you were aware when you were working in the prison of the significantly increased risk of passing away in custody that Aboriginal women faced, correct?
NG- Yes.
#JusticeForVeronicaNelson

AW - And you know, that a particularly cautious approach needs to be taken in relation to their health care, because of that risk, correct?
Nurse George - Of course I do.
#JusticeForVeronicaNelson

AW - Given all of the things that you knew ... I suggest that it should have raised in your mind a very real concern that she wasn't asleep. She was either unconscious or had passed away. Do you agree?
Nurse George - No
#JusticeForVeronicaNelson

Liam Brown, representing prison officers and secretary of Dept of Justice begins his questions, starting with questions about Nurse George's statement that she was scared of Officer Heath.

LB-Were you scared of her or was it just an unfriendly relationship?
G- Generally, when I see her I'm very nervous. And sometimes I can't go & approach her or anything like that. I don't know. Maybe that was her nature. I don't know. Because it's make me bit nervous and bit scary

LB - You didn't complain to your employer about her did you?
Nurse George - No, because very rarely I work with her. So once in a while I will see here at the prison, that is all.
#JusticeForVeronicaNelson

You say that Veronica did not appear unwell. And you're just sticking by that? That's your evidence.
Yes

LB - Prison Officer Brown told you that Prisoner Nelson had been buzzing up saying she was withdrawing heavily and her body was cramping mainly her legs and feet. She told you more than just that, she was suffering cramps didn't she?

George- They didn't tell me at that time whenever I was sitting there. They didn't make any comments about Veronica was feeling sick or anything on that time. They didn't tell me anything.
LB- No, but they were there with a nurse.
G- Yes.
LB-So they were relying on you

Stanton, appearing for LACW begins his questions.
S - Do you receive specific training on prisoners rights?
George - I'm not sure, I cant remember.
#JusticeForVeronicaNelson

S - Under the corrections act, prisoners have the right to access reasonable medical care and treatment necessary for the preservation of health. You understand that?
G - Yes
S -And you accept don't you that Veronica's treatment fell short of that standard?
G - Yes.

S- Do you receive any training on the Charter of Human Rights and Responsibilities?
G - Yes.
Ms George, did you have regard to Veronica's humanity when you treated her?
S - Yes
#JusticeForVeronicaNelson

Stanton - I suggest to you that if you did give due consideration to her humanity and inherent dignity, you would have spent more than 1 min with her at the trap.. and you would have followed up regarding her care that morning.. Do you agree with me?
Nurse George - Yes.

Stanton - So you accept that your treatment of her fell short of the standard of respect of humanity and inherent dignity required by the charter?
Nurse George - Yep.
#JusticeForVeronicaNelson

Nurse George finishes and court is adjourned. It begins again tomorrow at 10am with Prison Officer Tracey Brown taking the stand. The Coroner indicates Brown's evidence is likely to take all of Friday.
#JusticeForVeronicaNelson

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