Thread by @dhadjowa

Day 19 of the coronial inquest into Veronica Nelson's death in custody. Today the Court will hear continued evidence from the panel of medical experts. Remote link: csvic.webex.com/csvic/onstage/…
#JusticeForVeronicaNelson

There was consensus among the medical panel that Veronica's treatment in the days and hours before her death was inhumane.
Coverage of yesterday's evidence: sbs.com.au/nitv/article/2…
#JusticeForVeronicaNelson

"Gastroenterologist Sally Bell said the way the Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman died, alone, was "without dignity" and "unnecessary"."
#JusticeForVeronicaNelson
abc.net.au/news/2022-05-2…

A repeated content warning for today that the details covered in evidence and in related coverage are distressing
#JusticeForVeronicaNelson

Dr Matthew Frei (involved in developing prison opioid guidelines) gives evidence. Yesterday, medical conclave gave consensus view that these guidelines need to be revisited. Dr Frei agrees these guidelines almost a decade old, many new treatment developments and should be updated

Med Conclave asked for view on possible sub-acute unit [in prison] to offer substitution therapy to people entering custody, as a means of minimising suffering. Med Conclave confirms yes, substitution therapy is safer - lowering short-term risk and also overdose risk upon release

Research into post-release overdose risk: “We know people released from prison are at increased risk of death, and most of these deaths are due to preventable causes including drug overdose, suicide and injury’’ Professor Kinner said.
news.griffith.edu.au/2016/06/22/cal…

Assoc. Prof. Nico Clark: "What we have at the moment is care by a private provider [Correct Care] who doesn’t report to the Minister of Health & this is against WHO [guidelines on] healthcare for prison health… I think we should reconsider the governance of this healthcare.."

Professor Carla Treloar: "With people who have identities who attract stigma, the ability to have peer workers who can support them and advocate for their needs would be important as well."
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Dr Sally Bell, Gastroenterologist: “We would expect all staff involved in this kind of care to have appropriate cultural training, appropriate drug and alcohol training”
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Asked for view on whether prison healthcare more appropriately provided by Govt or public service vs private contractor, Medical Conclave give consensus view that healthcare in DPFC would be better run by Govt service rather than private contractor [currently Correct Care]

Medical Conclave states prison healthcare should be run by the Department of Health rather than the Department of Justice (in line with World Health Organisation guidelines for healthcare for prisoners)
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Prof. Megan Williams refers to 1991 RCADIC recommendation that when Aboriginal people are overrepresented in the prison, if there's a local Aboriginal Health Service they should have a role in delivering prison health services to First Nations people.
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Prof Megan Williams ref's broad def^n of health cited in Australian Institute of Health and Welfare and reporting the health of people in prisons, says "What we require is a match of the definition of health on paper and how it is supported in practice."
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Dr Issa testifies that given high rates of First Nations people in custody, should apply same metrics to resource and support services in custody (culturally targeted support at reception, specialty services incl. Aboriginal healthcare workers, drug and alcohol workers)

Professor Megan Williams points to Correct Care Australasia policy about culturally safe care for First Nations people and states, “We must question how practices align with the policy commitment”
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Med Conclave testify that Correctional Officers not having access to keys is a medical risk. Health staff may have had opportunity to consider diagnosis other than opioid withdrawal had they had opportunity to phys. observe Veronica's health condition
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“Veronica attempted to access healthcare by using her intercom, yet a sign on her door stating ‘New Reception: Do not open' The Medical Conclave is really unclear as to why this is.”
Veronica pressed the intercom about 44 times before dying in custody
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Prof Megan Williams gives evidence that it was not physically possible for Veronica to receive culturally safe care while locked in cell, stating that there was no capacity for Veronica to be supported in that space, or even communicated with by Aboriginal people in that context

The Medical Conclave repeats their position that healthcare delivery in a Corrections [prison] environment should be governed through Dept of Health rather than Dept of Corrections/Justice
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Other barriers to equiv care in community for Aboriginal ppl in prison: No Aboriginal leadership (staff or exec roles), no Aboriginal cultural governance, no partnership with Aboriginal Community Controlled health service, little evidence of cultural competence & cultural safety.

Medical experts testify that Corrections Officers are not healthcare professionals and as such would not have any insight into the clinical complexity that may arise when a patient is experiencing withdrawal: "Medical advice should not be provided by Corrections officers."

Intercom recordings from Veronica's calls for help from the cells in DPFC prison include audio from Corrections Officers who can be heard telling Veronica she needs to wait for medication to kick in, and saying "It's not an emergency, stop asking"
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Medical Conclave states their concern that Corrections Officer Brown, on night-shift in the Yarra Unit the night Veronica died, was more concerned with managing Veronica’s behaviour rather than escalating Veronica’s Care
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Inquest hears the defn of medical unit as offering 24 Hour care.
Conclave makes ref to statement of Ms Fuller (Dep CEO, Correct Care), which clarifies that DPFC med centre does not have acute or sub-acute inpatient beds on site. Med Conclave raised serious concerns about this

Med Conclave: ​​"This [absence of acute and sub-acute beds] is a major major and noteworthy concern. A Correctional Facility, regardless of its demand or sentence status, is advised to have a medical clinic with 24-hr health care including after hours."
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Prof Carla Treloar speaks to the issue of stigma, noting that Veronica lived with multiple intersecting identities that would attract stigma, including being: Female, an Aboriginal person, a person who injects drugs, a person w drug dependence & a person previously incarcerated

Prof Treloar:“It's undoubted those identities and experiences would…attract stigma in the community not just in prison, but the actions that impact the stigma must be seen in relation to the absolute power of the justice system and the inability as such of Veronica to seek care”

Prof Treloar makes reference to structural stigma in relation to Vic bail reform laws & how these laws have directly impacted on First Nations women: These laws have resulted in an increase of 440% of First Nations women being held on remand in bail since their introduction

Prof Treloar speaks on rapid withdrawal pack that Veronica was provided on arrival at DPFC, notes that Veronica was forced to withdraw against her wishes. Authorities had deemed that she must experience and endure rapid withdrawal.
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Prof Treloar continues on inequity in this prison healthcare, noting if Veronica was in the community, she would have been able to access her preferred medication, or had options to seek treatment elsewhere or indeed other options to avoid withdrawal.
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Prof Telour gives evidence that drug dependency is not seen as a legitimate health condition, and that this is core to the understanding of stigma
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Prof Treloar speaks to limits of training in addressing interpersonal, institutional and internalized stigma: “One very common response to talking about stigma is.. we need a new training program for our workers. I would strongly suggest that that by itself, will be ineffectual.”

Prof Treloar continues: “Training workers…has limited impact without bringing the whole of the org along with it. That organization needs to...continually learn about the ways in which stigma is shaping the care that it gives & how this is received by people seeking care.”

Prof Treloar states, “Stigma towards people who inject drugs is pervasive and ubiquitous. I've measured it many times. The findings are, without doubt, indicating pervasive and ubiquitous stigma.”
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Court breaks and then moves to questions of medical experts as to how barriers to accessing care be removed to improve health outcomes for Aboriginal women and women with drug dependence, and to reduce the risk of harm for women with drug dependence.
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Dr Bonomo:“It seems to be a punitive form of healthcare [in prison]… It's punishment enough to be incarcerated and to have your freedoms removed. The healthcare that is provided once you're [incarcerated] should not be with a punitive lens on it.”
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Ass. Prof Megan Williams, responding on healthacre barriers: “We must ensure as per recommendations of other investigations that Aboriginal women are incarcerated as a last resort & that all other options have been genuinely exhausted to divert Aboriginal women away from DPFC”

Ass. Prof Williams calls making DPFC care culturally safe a “conundrum”: "We must ensure culturally safe care occurs for incarcerated [First Nations people] there. But.. from my understanding of Aboriginal culture, it does not follow to make a center like that culturally safe…"

"We must also invest in community-based options so that there are genuine options to divert Aboriginal women before any incarceration at DPFC.That means also investigating Aboriginal justice options & genuinely resourcing them," Ass. Prof Megan Williams
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Prof Williams also comments on the limits of training as a tool to transform behavioural changes and practices of med practitioners. She suggests that working in partnership with Aboriginal Community Controlled Organisations could bring about improvements of health care provided

Prof Williams refers to recommendation 127 of RCIADIC - the need for appropriate healthcare for Aboriginal people in custody. She notes the importance of the role of Aboriginal Community Controlled Health Organisations in reviewing and guiding prison health standards

Dr Sally Bell, referring to provision of healthcare in prisons: We have a clear demonstration of a culture of ignoring the person, of following the custodial protocols and of siloing...It is very clear that there is...a lack of respect for those incarcerated

Prof Treloar comments on the very high rate of reincarceration of people who inject drugs and notes that this signifies the importance of appropriate healthcare service provision in the community for people who inject drugs

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Prof Treloar notes that the decriminalisation of the personal use of illicit drugs would very significantly reduce the numbers of people incarcerated

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Medical Conclave testify that it’s very difficult for them to go into details of clinical governance in DPFC and Correct Care or to thoroughly examine "culture and the differences between policies and what actually happens" from looking at policies
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Medical conclave critical of the previous review of Veronica's death by Justice Health [unit of Dept of Justice & Community Safety, resp for policies, standards & contract management of prison health], noting that it, “failed to detect many of the issues we have discussed today.”

Of the Justice Health review of the circumstances around Veronica's death, Dr Bells says: “Reviewing yourself is not good practice”.
The Medical Conclave calls for "an independent review by an independent organization."

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Medical Conclave unanimously recommends that a detailed independent review of the Justice Health review into Veronica's death be undertaken by Safer Care (an independent reviewer body) and that the clinical practices of Correct Care care are examined

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Coroner notes he's likely to receive a closing sub that Justice Health review is now against the weight of the evidence. Discussion as to how, if the Coroner reaches finding that Justice Care review (currently on public record) isn't supported by evidence, this might be expunged.

The court hears that Correct Care, the medical health provider in DPFC prison where Veronica died, did not conduct its own review into her passing.
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The court hears evidence from medical experts that a review by the healthcare provider after a death in custody is necessary to “understand systems failings, opportunities for improvement opportunities for staff development”. But did not occur following Veronica's death

Dr Clark gives evidence from his experience that the usual practice would be to, "Immediately do a review, a comprehensive root cause analysis of the events leading up to and after the death of one of the prisoners [and thatt] put them in prison."

The court hears of 2017 report that found that 41% of prison officers rated health care at Dame Phyllis Frost Centre as poor or very poor. Corrections Victoria asked if they engage with prison officers to monitor their views about the health care adequacy; the answer - no

The Conclave is asked if they expect that if Veronica had presented the way that she did in the community, if they could reasonably expect that she would have found herself in a hospital setting
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Medical Conclave: Veronica would have had.. access to care if she was in the community. Unfortunately, because she wasn't in the community, she didn't have the opp to make that decision for herself, or at least be assisted by people who could facilitate access to care for her.

Asked if Correct Care policy [transfer to hospital if patient's condition deteriorates & req's tertiary care & that this dec'n should be in consultation with medical officer] is problematic as could cause person in positionn of Nurse Hill to feel fettered, RN Ham answers, yes

Andrew Woods, Counsel for Percy Lovett says Coroner’s scope includes whether Veronica’s Aboriginality impacted on her treatment: “What happened to Veronica seems a very extraordinary set of events & that there might have been something more sinister at play”

Ass. Prof Williams: "It takes critical self-reflection & support from colleagues to identify unconscious bias in our own practices...In my review.. I can only comment on the absence of strategies to address unconscious bias in this instance"
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Counsel for Fitzroy Legal Services asks Ms Fuller [Correct Care] if she is aware that Correct Care guidelines on suboxone (4mg one day 8mg next day) for opiate withdrawal are inconsistent with national guidelines

Ms Fuller, Correct Care, gives evidence that these are guidelines for prescription of Suboxone and that medical practitioners can use their discretion to prescribe suboxone within their own clinical judgment.

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Contrary to Ms Fuller's evidence about practitioner discretion re prescription of med's for opiate withdrawals , Dr Runcares has previously given evidence that in practice a ‘one size fits all’ model is adopted in the Medical Centre run by Correct Care at DPFC prison

Dr Nico Clark gives evidence that the Medical Conclave can see no reasons why Correct Care would not immediately adopt national guidelines around prescription of Suboxone, which recommends that treatment should be adjusted to the individual rather than a 'one-dose meting'

Counsel for Fitzroy Legal puts to Ms Fuller [Correct Care] that by not allowing people to commence opiate subst. therapy on arrival at prison & by only offering a rapid withdrawal pack Correct Care’s policy is essentially a policy of involuntary withdrawal.
Fuller disagrees.

Dr Clark comments on “bizarre" Justice Health policy of not allowing maintenance treatment for opiate withdrawal to be commenced if someone is incarcerated for less than 6 weeks
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The Court breaks for lunch and then resumes with questions of the Medical Conclave about what, if anything, could be done to improve the cultural safety of Aboriginal women incarcerated at DPFC prison
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Ass. Prof Williams responds to questions about cultural safety of Aboriginal women, says that DPFC should partner with Aborginal Community Controlled Organisations (ACCOs) to ensure that cultural safety of women incarcerated at DPFC can be improved.

Ass. Prof Williams says there is a barrier to ACCOs partnering because these organizations are not funded to do so and are reliant on Medicare funding, and that prisoners are excluded from Medicare.
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Ass. Prof Williams states that additional state funding must be made available to Aboriginal Community Controlled Organisations which takes into account the high rates of representation of First Nations people in prison in Victoria
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Medical Conclave notes that conditions at DPFC would not have significantly improved since Veronica’s death in custody & that the workforce probably isn't at the standard that's required for cultural safety right now
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Medical Conclave says urgent mechanisms need to be considered to improve culturally safe practice at DPFC prison now.
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Dr Clark points to a gap: There isn't a mechanism for the review of private healthcare Institutions such as Correct Care in the same way that we have for the public health system. Dr Clark believes this is another reason why prison healthcare should be public rather than private

Dr Hunt, Victorian Aboriginal Health Service: "I've worked at many different Aboriginal Community Controlled Health Organizations over more than 25 yrs. Every single one of them would love to be more involved in improving [healthcare in prisons]."
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Dr Hunt comments on the same rec's emerging for the last 3 decades: “It's interesting to reflect why we still have very similar recommendations coming through…I think it is, you know, lack of resourcing and also a lack of [system] accountability to the Aboriginal community.”

Dr Hunt: We've talked about clinical governance, but what's the accountability mechanisms for clinical and other governance to the Aboriginal community? Because that has to have been a failure there for us to be still here recommending for more involvement [of ACCOs].

Dr Hunt: "It needs a significant investment of resources for Aboriginal community-controlled health services to bring their expertise… Without that, you know, well, I can't see how things will change"
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Counsel Assisting: Can you identify the most significant roadblocks to the recommendations [of the 1991 RCADIC] being carried through?

Dr Hunt: Money and political will

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Counsel Assisting asks Scott Swanwick, Director of health services, Justice Health, "Why are Aboriginal people still dying in custody in the numbers that they are?"

Swanwick responds, "Because they are in prison. They’re over-represented."

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The medical conclave gave evidence yesterday that given Veronica’s weight, they did not believe it was safe to go through opioid withdrawal. Currently there are no clinical parameters around when detox from opioid withdrawal in custody is considered unsafe for people.

Asked if it would be possible to develop a set of these guidelines around opiate detox & withdrawal in prisons, Dr Nico Clark gives evidence that it would be difficult to define all the possible scenarios, but a doc to outline some of those parameters could be developed.

Counsel for Aunty Donna confirms with Correct Care that their accountability is by way of contractual obligations to Justice Health. Counsel puts that the absence of internal review by Correct Care [after Veronica's death] meant Correct Care failed their contractual obligations

In evidence provided earlier this week, Aunty Vickie Roach suggested that Prisoners should have access to regular doctors. Counsel for Aunty Donna, Veronica’s Mum, asks about the impact of the exclusion of Prisoners from Medicare and the impact of this on the provision of care.

Dr Christopher Vickers, Gastroenterologist: “The Medicare platform is designed to be universal health care for all Australians. There cannot be any exceptions.”

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Dr Hunt, Vic Aboriginal Health Service, gives evidence that Medicare access would help, but its not sufficient funding to provide care to people with complex health needs.

“Medicare would be of assistance, but it wouldn't be enough.”

Dr Hunt, VAHS, notes that there are many barriers to Aborginal Health Services delivering healthcare in prisons, but that “to be able to deliver stable care we [would] need a reliable source of funding.”

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CA asks Melissa Westin, Deputy Commissioner of Corrections if prison guards are allowed to call an ambulance. Westin gives evidence there is no policy stopping prison guards from doing this

Numerous prison guards have given evidence that they're not allowed to call an ambulance

CA asks the Conclave if they believe the systemic problems identified are repairable and fixable

Dr Bell: The job of repair is massive and really involves system changes, structural changes, personal changes, a change to ethos and culture in the organisation.

Medical Conclave of the consensus view that health and justice must be separated to address systemic problems

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Dr Bell: "Your previous questions about why there has been no change since the RCIADIC point to the fact that implementation of change is a big problem. You can write as many policies as you'd like, but if you don't implement any change, they won't be practised."

Medical conclave of the view that changes to healthcare provided in Dame Phyllis Frost Centre (DPFC) prison needs to happen now - “We can’t wait months for reviews and policy.”
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The inquest is adjourned until 10am Monday morning when the 'Administration of Justice Hot Tub' (made up of the Adminstration of Justice Stakeholder Panel & Adminstration of Justice Evidence Conclave) will give evidence.
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