Thread by @dhadjowa

Today is the 23rd day of the inquest into the death in custody of Veronica Nelson. In these last two days, we expect to hear from significant institutional witnesses from the Dame Phyllis Frost Centre and Correct Care Australasia.
#JusticeForVeronicaNelson

We encourage anyone who can to show their support in person at the Coroners' Court from 10am today and tomorrow.
#JusticeForVeronicaNelson

If you can't make it to the Coroners Court today, you can listen in at this link — csvic.webex.com/ec3300/eventce… #JusticeForVeronicaNelson

The Coroner opens by telling the bar table, in the interests of time, to expect half of their estimated time for cross-examination of these institutional witnesses — leaning in favour of Veronica's senior next of kin. #JusticeForVeronicaNelson

We are now hearing from Governor Tracy Jones. Jones is the General Manager of Dame Phyllis Frost Centre. The Coroner begins by conferring Jones a certificate protecting her against self-incrimination. #JusticeForVeronicaNelson

Jones: 'I have general oversight of the women and staff of DPFC. My role is generalist — managing risk, prisoner complaints, budget, performance, notifiable incidents.'
Q: 'Are you the top of the tree?'
Jones: 'Effectively.'
#JusticeForVeronicaNelson

Jones: 'I meet with the prisoner representative group once a month. I take on notice their feedback for how to improve the prison. Those meetings are limited. If i believe it's reasonable [...] I'll put it into a local operating procedure.'
#JusticeForVeronicaNelson

Q: 'Do you expect the medical centre [inside] will service prisoners' health needs short of hospitalisation?'
Jones: 'This is a matter that's been murky for some time. I believe there needs to be an intermediate option.'
#JusticeForVeronicaNelson

Jones: 'Currently the two options are: that the woman is placed in a cell if unwell or she goes to hospital. [...] I don't think the medical centre is equipped to deal with more complex medical issues for women in our care. I believe the medical centre is under-resourced.'

Jones: 'I've been thinking about this prior to and since Veronica's passing. [...] I approached the architects building our units, I've asked ten beds to be put aside for an 'ice cube': a unit where women heavily withdrawing from drugs can be monitored.' #JusticeForVeronicaNelson

Q: 'Is there research being done in pursuit of this outcome in relation to addiction medicine and the services necessary?'
Jones: 'Conversations are not specific yet. The unit is due to be finished early next year. [...] Has research been done? No.'
#JusticeForVeronicaNelson

Jones: 'DPFS is a system within a prison. [...] Those ten beds would be used in a flexible way.'
The question is put whether 'flexible' means they could be used for other purposes.
Jones: 'I'm yet to have those more comprehensive conversations.'
#JusticeForVeronicaNelson

Q: 'Do you agree that there are challenges by operating with a private service for the care of the prisoners?'
Jones: 'I think there's been some challenges with the medical centre, but I've seen an improvement. [...] The relationship needed work.'
#JusticeForVeronicaNelson

Q: 'Between your prison and Connect Care staff?'
Jones: 'Between everyone, including the women. People lost faith in CCA for a time there. The staff and the women — the number of prisoner complaints I received had significantly increased.'
#JusticeForVeronicaNelson

Q: 'In a 2017 report, 71% of [women inside] said it took a long time to see a doctor, has that been rectified in the last five years?'
Jones: 'More recently, it's been rectified. [...] Women's health needs are complicated and complex.'
#JusticeForVeronicaNelson

Q: 'Since when [has it improved]?'
Jones: 'I would say since the current health services manager returned, things have improved. [...] I would say in the last few months.'
#JusticeForVeronicaNelson

Q: 'Prior to that, you observed confidence in CCA at a low — beyond that of the 2017 survey?'
Jones: 'Yes.'
#JusticeForVeronicaNelson

Q: 'What does medical clearance mean for you?'
Jones: 'It means to me that the woman no longer needs to be housed in the medical centre and that she's fit and well enough to return to her unit.'
#JusticeForVeronicaNelson

Q: 'How would your staff know that she's medically cleared?'
Jones: 'They would be told that [by medical staff].'
Q: 'It requires an assessment by a doctor that a prisoner is medically fit to be locked in a cell [...] without observation?'
Jones: 'Yes.'
#JusticeForVeronicaNelson

Jones: 'You never know what's going to happen with the women, they come in very unwell very often and we have to take it on good faith that [they've been medically cleared]. [...] There's no knowing what's lurking in a hidden medical condition.'
#JusticeForVeronicaNelson

Jones: 'If [Veronica] wasn't given medical clearance, she shouldn't have gone to Yarra. I would like to see a more formal documentation process [...] it's something we need to fix immediately so this doesn't happen again.'
#JusticeForVeronicaNelson

Jones: 'I don't think my staff are medical experts. You could make a general observation, like if someone is unsteady on her feet. [...] but I wouldn't like to see custodial staff trying to diagnose a woman's medical condition.' #JusticeForVeronicaNelson

Jones: 'Each staff member will have their own interpretation of how a woman's presenting. Some may not have seen Veronica as unwell, others may have seen her as extremely unwell. [...] People would use different language.'
#JusticeForVeronicaNelson

Q: 'One of the problems that occurred in this case was that a number of staff were aware of the degree to which [Veronica] had been vomiting. [...] [W]hat sort of process must be put in place for [staff to convey this information]?' #JusticeForVeronicaNelson

Jones: 'The reception assessment isn't the place for that. [T]hat should have been reported to the supervisor and noted in the log book if she was that unwell. I don't know if she presented better the following morning, but the supervisor should have read all the facts.'

Jones: 'Personally I would have gone and met with the woman, but time may have gotten away from [the supervisor]. There is a process in place already. Veronica should have been monitored every hour, and someone recorded these types of things.'
#JusticeForVeronicaNelson

Jones: 'The process is there for that reason. Was it followed? Sounds like it hadn't been.' #JusticeForVeronicaNelson

A lengthy question is now being put to Governor Jones, outlining what the Court has heard already about Veronica's passing. Q: 'There were over thirty intercom calls overnight by Veronica, but she's not seen until 10.45 in the morning.' #JusticeForVeronicaNelson

Q: 'In those calls, the response for the most part from the officers is: "There's not anything we can do." She receives one drink, socks and breakfast. But, in terms of medical assistance for an unwell woman, there was actually very little assistance.' #JusticeForVeronicaNelson

Q: 'What would you expect the response to be?'
Jones: 'This is some of the murkiness I mentioned […] There needs to be a better process when staff are checking on women, rather than relying on intercom usage after hours.'
#JusticeForVeronicaNelson

Jones: 'I don’t agree that staff don't want to help or don't care. Staff don't open cell doors after hours due to safety and security reasons. [...] It is practice that medication is given through the trap after hours.'
#JusticeForVeronicaNelson

Q: 'What should trigger a code black?'
Jones: 'Where a prisoner needs immediate urgent care.'
#JusticeForVeronicaNelson

Q: 'We also know that no one there had information about her health status.'
Jones: 'We're not privy to women's health information.'
#JusticeForVeronicaNelson

Jones: 'We're there to service the women to ensure they're looked after and cared for. What we have is a complex correctional environment [...] women are being reminded in short bursts. This revolving door creates a churn that's hard to resource for.'
#JusticeForVeronicaNelson

Jones: 'The women's medical needs are very complex and challenging. There are unfortunately cases like Veronica's presentation which are not rare occurrences.'
#JusticeForVeronicaNelson

Q: 'The responsibility of health services in prisons is to provide healthcare equivalent to what prisoners can receive in the community, do you accept that?'
Governor Jones: 'I do accept that.'
#JusticeForVeronicaNelson

Q: 'Are there ways you would be assisted if medical care was provided through a system other than a private corporation?'
A: 'I’m not sure that’s for me to say. Whether you’re a private or public service, there’s always funding and resourcing issues.'
#JusticeForVeronicaNelson

Counsel Assisting refers to last week's expert Medical Conclave, who described 'punitive models of healthcare' inside 'with a reluctance to provide treatment.' Q: 'What can you do to ensure there is not a punitive model of healthcare in DPFS?'
#JusticeForVeronicaNelson

Jones: 'I don’t believe it’s an intentional punitive approach, I think that most of the staff are there because they want to look after the women and do right by the women, and they are under-resourced and busy.' #JusticeForVeronicaNelson

Jones: 'I don’t agree women should wait months and months [...] scared and anxious. In a corrections environment, not being able to tell them when they're going to hospital for security reasons, it's tricky. [...] There's always room for improvement.' #JusticeForVeronicaNelson

Jones: 'To answer what I can do — I could work on having a good relationship with medical providers, whether public or private, to ensure we are working well together for the women.' #JusticeForVeronicaNelson

Governor Jones asks to speak as the Court resumes after morning recess: 'On behalf of DPFS and myself, I want to offer my sincerest apologies and condolences to the family of Veronica and pay my respects. I apologise that I didn't do this earlier.' #JusticeForVeronicaNelson

Q: 'When Veronica stayed overnight, it was prison staff who were receiving verbal communications?'
Jones: 'Yes, the only time they would go to the control room is if they weren’t answered by a medical officer.'
#JusticeForVeronicaNelson

Q: 'Do you have an expectation that a prison officer would convey to the nurse the communications with the prisoner, in this case Veronica?'
Jones: 'Yes.'
Q: 'When Veronica said 'I've vomited', that should have been passed to the nurse?'
A: 'Yes.'
#JusticeForVeronicaNelson

Jones: 'The way it is set up [...] the nurse could hear the intercoms if she was sitting at her nurses' station.'
Q: 'When you say they could have heard — is that because it always comes over a speaker?'
Jones: 'Yes.'
#JusticeForVeronicaNelson

Q: 'Are you saying that medical observations should have been placed on Veronica while she was in the health centre?
Jones: 'That’s not for us to determine, that’s a matter for CCA.'
#JusticeForVeronicaNelson

Q: 'When you say it's not a matter for you — you have a prisoner who has been unwell enough to say in the medical centre overnight.'
Governor Jones: 'But we are not doctors or nurses [...] for management observations you can observe through the window.'
#JusticeForVeronicaNelson

Counsel Assisting: 'What options are there for your staff to get medical help that they believe a person needs?'
A: 'The nurse would have had to call the on call doctor to say Veronica is presenting with these symptoms, that’s my understanding.'
#JusticeForVeronicaNelson

Jones: 'It’s open to interpretation. We rely heavily on our medical providers to advise us. If medical are saying she’s fine, nothing else needs to be done, staff will accept that. Is that good enough? In this instance it wasn’t, no.' #JusticeForVeronicaNelson

Counsel Assisting: 'I understand that you have your responsibility and CCA have theirs, but what I’m suggesting is that there is a big gap where someone like Veronica does not get the help she needs.'
Governor Jones: 'I agree it’s a systems problem.'
#JusticeForVeronicaNelson

Counsel Assisting: 'Do you accept that that team work [between prison staff and medical staff] wasn’t working effectively the night that Veronica was in your care?'
Governor Jones: 'I accept there is definitely room for improvement.'
#JusticeForVeronicaNelson

Q: 'Would it not be of assistance if [supervisors] were aware of a person's health problems?'
A: 'Not necessarily, we are not trained in any way around medical or health situations.' Jones says what would be helpful instead would be 'understanding risk'.
#JusticeForVeronicaNelson

Counsel Assisting asks what Jones would change now.
'I think we need to tighten [the medical clearance] process immediately. We are still having very unwell Aboriginal women and non-Aboriginal women come in. We are hyper-vigilant about that.'
#JusticeForVeronicaNelson

Governor Jones: '[We] aren’t fit for purpose to have a[n] [unwell] woman overnight, which is why CCA would rather send a woman to hospital, which isn’t good enough. We need that new intermediate option. I’m hoping a new centre will achieve that.'
#JusticeForVeronicaNelson

Q: 'When did you first agitate with Justice Health to get some changes in place in relation to these issues?'
Governor Jones: 'Probably not long after Veronica passed away. It wasn’t as a direct result of Veronica's passing.'
#JusticeForVeronicaNelson

Counsel Assisting now moves to how DPFC reviewed Veronica's passing. 'There was a formal incident debrief held at the prison?'
Governor Jones: 'Yes.'
#JusticeForVeronicaNelson

Q: 'There were a number of people who had direct contact with Veronica who were not included — why would that be?'
Jones: 'Generally, formal debriefs are only for anyone directly involved in the incident or immediate lead up.'
#JusticeForVeronicaNelson

Counsel Assisting: 'When you talk about 'the incident', are you referring to finding Veronica's body on the cell floor?'
Jones: 'Correct.'
Q: 'As opposed to what led to her passing?'
Jones: 'Correct.'
#JusticeForVeronicaNelson

Counsel Assisting: 'So, it's not a process of reviewing how the prison could do better after someone's passed in their care?'
Jones: 'No. [...] It's about checking in with staff and people who attended the incident as a matter of support.'
#JusticeForVeronicaNelson

Counsel Assisting now moves to 'missed opportunities where Veronica's care could be escalated.'
She asks about a 3.58am call in which Officer Brown asks Veronica a question twice. There was no response.
'Was that a serious failure to comply with her duties as night watch?'
'Yes.'

Q: 'Ought not corrections staff exercise their own discretion or compassion to ensure that a woman is safe?'
Jones: 'It’s hard to get 500 staff to exercise a level of discretion because again everyone has their own interpretation of what’s required.' #JusticeForVeronicaNelson

Governor Jones: 'The correctional system is very black and white — there's so many staff from all walks of life, different levels of emotional intelligence. Some would say they should have checked on Veronica, others would say I assumed she was asleep.' #JusticeForVeronicaNelson

Jones: 'The cells are dark. You shine a torch in a woman’s face to check she’s alive and breathing, it’s intrusive and antagonises the woman. It's also a big task for the staff to go and look in a cell to check if a woman is asleep or dead, to be blunt.' #JusticeForVeronicaNelson

Counsel Assisting: 'This was a woman who had been screaming out for help [...] Doesn't there need to be some discretion applied, whether founded in duty or compassion, to check she's okay?'
Jones: 'I don't disagree.'
#JusticeForVeronicaNelson

Jones is now taking questions from counsel for Aunty Donna Nelson (Rishi Nathwani).
Q: 'Do you agree the standard of healthcare Veronica received was not the same she would have received in the community?'
A: 'I don’t know what medical care she received in the community.'

Q: 'She could have easily been taken to a hospital [if she wasn't in prison], do you agree?'
A: 'Yes.'
Q: 'So it doesn’t look like Veronica received the same standard of healthcare, do you agree?'
Jones: 'Yes.'
#JusticeForVeronicaNelson

Q: 'Why hasn’t there been a change in relation to medical clearance?'
Jones: 'Because this is only coming to my attention since the inquest.'
Q: 'Is the only review you have been involved in the debrief?'
A: 'I don't count debriefs as a review.'
#JusticeForVeronicaNelson

Q: 'Have you reviewed the debrief before coming to court?'
Jones: 'I have refreshed my memory, yes.'
Q: 'Do you think it is an adequate review or brief of what happened to Veronica Nelson?'
Jones: 'Not now that I know what I know now.'
#JusticeForVeronicaNelson

Q: 'Why does it take a coronial inquest three years after someone’s death for you to know this?
Jones: 'I don't conduct my own investigations, I rely on officers reports and the immediate situation. This [information] wasn’t made available to me.'
#JusticeForVeronicaNelson

Q: 'Whose failing is that?'
Governor Jones: 'System failing.'
#JusticeForVeronicaNelson

Q: 'Since Veronica’s passing there has been another Aboriginal death custody [in the medical unit], so it is still happening?'
Governor Jones: 'I think it’s a different situation, but I don’t deny that another Aboriginal woman died in our care.'
#JusticeForVeronicaNelson

Q: 'The question that will be asked repeatedly by Aunty Donna is: 'why isn't there change?' Why do we have to wait for recommendations from the Coroner?'
Governor Jones: 'I will make the changes with what I know are the gaps.'
#JusticeForVeronicaNelson

Q: 'Why don’t you know? You are the head of this system. I accept that you don’t want people dying on your watch, but why don’t you know?'
Jones: 'Because I feel like I might have been let down by people who should have done a more thorough review.'
#JusticeForVeronicaNelson

Q: 'I am being critical of you for not finding out. Someone has died on your watch. Isn’t the onus on you to get statements from your staff?'
A: 'Well no, the onus isn’t on me to do that. It's on an independent person. I can’t review my own prison.'
#JusticeForVeronicaNelson

Jones: 'Based on what I had heard, based on the intercom calls that I had heard to Veronica that night I felt that Officer Brown had spoken to her with sensitivity and compassion, obviously not realising she would pass that night.' #JusticeForVeronicaNelson

'[Officer Brown] was lying to her.'
Jones: 'I wasn’t aware of that.'
Q: 'It would be obvious with a basic review that she was lying to her. Have you listened to her phone calls with Veronica since you have decided you were proud of how she behaved?'
#JusticeForVeronicaNelson

Q: 'Do you still stand by that?'
Jones: 'I do.'
Q: 'I asked her about this and [Officer Brown] accepted lying on five occasions. She accepted that she didn’t behave with integrity and sensitivity to Veronica. You know [your] debrief was used by JARO?'
#JusticeForVeronicaNelson

Q: 'JARO effectively said there was nothing to see here [as a natural causes death]. That goes to the Coroner and can be a factor of whether or not an inquest is heard, do you agree?'
A: 'I agree.'
#JusticeForVeronicaNelson

Counsel for Aunty Donna Nelson talks though the evidence of Officer Brown's conduct. 'She accepts that she didn’t speak to the nurse before giving medical advice [that wasn't accurate]. Is [that] appropriate?'
A: 'No.'
#JusticeForVeronicaNelson

Q: 'Would that have changed the way you [said in your debrief that you] were proud of how [Officer Brown] had dealt with Veronica's calls?'
Governor Jones: 'Of course.'
#JusticeForVeronicaNelson

Q: 'Is it appropriate for your staff to be recommending something that Veronica cannot actually receive?'
Jones: 'I think I was okay with her saying that. I felt she was trying to at least help her and provide some comfort.'
#JusticeForVeronicaNelson

Governor Jones: 'I wasn’t aware [Officer Brown] had lied in her testimony. All I was aware of was the intercoms. I felt that she was at least trying to be compassionate.' #JusticeForVeronicaNelson

Q: 'Do you agree that [Officer] Brown was in effect Veronica’s contact for care for her health? She was Veronica’s only point of contact?'
Jones: 'Yes.'
Q: 'Were there any attempts to make sure Nurse George could attend?'
A: 'I can’t answer that, I didn’t do the invites.'

Counsel for Aunty Donna Nelson: 'I think you accept that lying to a prisoner is wholly inappropriate, whether by intercom or otherwise.'
Governor Jones: 'Yes.'
#JusticeForVeronicaNelson

Q: 'The rules for review of a death in custody say the purpose of your debrief is to critically examine the incident. Do you accept that you didn’t critically examine the incident?'
Jones: 'The debrief didn’t, no. But again it’s not the role of the formal debrief to do that.'

Q: 'Do you agree that there was not a root cause analysis done in relation to why it was that Veronica died on your watch?'
Jones: 'I do.'
#JusticeForVeronicaNelson

Q: 'Do you agree that not one of the medical practitioners who had any involvement with Veronica were involved in the debrief?'
Jones: 'I can’t comment on who wasn’t invited and who wasn’t, but I would have invited them if they were directly involved.'
#JusticeForVeronicaNelson

'Aunty Donna’s view is that the moment Veronica entered that prison, you were all jointly responsible for her care, and you failed in that care.'
Governor Jones: 'I accept that there’s a lot of improvement that needs to be done across the system.'
#JusticeForVeronicaNelson

Counsel for Aunty Donna: 'Do you or do you not accept that you failed with the care of Veronica Nelson?'
Governor Jones: 'The fact that she died in our care means we failed her.'
#JusticeForVeronicaNelson

The Court has resumed after a short recess. Governor Jones is being examined on an expansion to the Dame Phyllis Frost Centre. Jones had previously told the Court she was advocating for a subacute medical unit as part of the expansion. #JusticeForVeronicaNelson

Q: 'That includes 106 new beds, correct? And it's to accommodate 106 new inmates essentially, isn't it?'
A: 'No, it's to replace old beds that are no longer fit for purpose.'
#JusticeForVeronicaNelson

Q: 'And it might be obvious from what you've said but that won't do anything to change the sort of issues that we're looking at here.'
Jones: 'Yes.'
#JusticeForVeronicaNelson

Q: 'Do you agree that a proper and effective system of escalation would have meant that Veronica's deterioration would have been identified firstly, and secondly, that something would have been done about it?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'If they deem it necessary, [prison staff] are allowed to call an ambulance without going to medical staff?'
A: 'That's correct.'
Q: 'The evidence of officers themselves was that they were emphatic, saying we are not allowed to call ambulances.'
#JusticeForVeronicaNelson

Q: 'What I'm putting to you is that the difference between those two positions shows that there's still confusion in the system two and a half years later, correct?'
A: 'I agree.'
#JusticeForVeronicaNelson

Q: 'It doesn't take much imagination to think of an urgent matter in prison where that confusion could lead to death or a serious deterioration.'
A: 'They wouldn't necessarily call an ambulance at three am, as a prison officer without having done some kind of reporting up first.'

Q: 'You accept more broadly, you accept that this creates risks?'
A: 'I do.'
#JusticeForVeronicaNelson

Q: 'In your position as the governor of the prison, you're obviously aware of the disproportionate deaths in custody of Indigenous people as compared to non-Indigenous people?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'We heard clear evidence from prison officers that they're not aware that Indigenous people are more likely to die in prison than non-Indigenous people. That was an officer who was on the end of calls at a particularly acute period of time in Veronica's deterioration.'

Q: 'Do you agree that it's a failing of the system that the people who are dealing with a very unwell Aboriginal woman in custody don't know that there are particular risks faced by Indigenous people in that vulnerable context?'
A: 'That concerns me.'
#JusticeForVeronicaNelson

Governor Jones: 'That concerns me to hear that one of my staff was not aware of that. Yes, it does, when they're trained in Aboriginal cultural awareness.'
#JusticeForVeronicaNelson

Q: 'The first three days in custody is a period of particular heightened risk to Indigenous people of dying in custody. Is that something you'd heard before? You'd accept that the prison needs to do more to look after Indigenous women in custody during that three days?'
A: 'Yes.'

Q: 'One of RCIADIC's significant recommendations was that thorough and regular cell checks need to be conducted for Aboriginal people in custody. Would you’d accept that recommendation had not been implemented at DFPC on the 1st?
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'The evidence that's been given about was that she was presenting over the intercom on the night of the first, it was accepted that [officers] should have opened the door. Would you agree with that?
Jones: 'Absolutely. In hindsight, yes.'
#JusticeForVeronicaNelson

Q: 'Do you agree that without going through the process and listening to [the calls Veronica made] you can't effectively performance manage your staff if they've acted inappropriately?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'Do you remember that Counsel Assisting put to you that as a matter of discretion, initiative and basic human compassion they should have checked on Veronica?'
Uncle Percy Lovett's counsel is now playing to the Court a call for help Veronica made.
#JusticeForVeronicaNelson

Counsel for Uncle Percy Lovett: 'You'd accept that the failure to go to Veronica's cell after taking that call shows a complete lack of basic human compassion?'
Governor Jones: 'Yes.'
#JusticeForVeronicaNelson

Questions now from the Law and Advocacy Centre for Women, who is going through international and state-based human rights standards for the treatment of women prisoners. #JusticeForVeronicaNelson

Q: 'Do you receive specific training in relation to your obligations under the Charter?'
A: 'Yes.'
Q: 'When did you last do that training?'
A: 'About three years ago.'
#JusticeForVeronicaNelson

Q: 'What about your staff, prison officers? Do they receive specific training or pre-service training?'
A: 'Correct.'
Q: 'And is there ongoing training?'
A: 'There is no refresher training.'
#JusticeForVeronicaNelson

Q: 'Do you receive as part of your training specific training in relation to what's known as proportionality?'
A: 'Yes.'
Q: 'And when and how human rights can be limited?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'In must cause you concern that the Medical Expert Panel said, in their words, that 'Veronica died without dignity and alone'.'
Governor Jones: 'Yes, that does cause me concern.'
#JusticeForVeronicaNelson

Governor Jones: 'My preamble with every recruit squad is that you treat the women with dignity and respect and that they're not second class citizens, and we need to be humane and respectful in our interactions. It's clearly not enough. I accept that.' #JusticeForVeronicaNelson

Q: 'Because prison officers and care staff need specific training about how human rights inform decisions that can be life and death decisions, correct?'
Governor Jones: 'Yes.'
#JusticeForVeronicaNelson

Q: 'There will be a net increase in beds at DPFC?'
A: 'A very small net gain.'
Q: 'When there's more beds or prisons expanded, there may be more people remanded in custody, you understand?'
A: 'I understand that, yes.'
#JusticeForVeronicaNelson

Q: 'If that leads to an increase of Aboriginal women being held in custody, being prisoners, that's not a sign that this system is being successful, is it?
A: 'No.'
Q: 'It's a sign that the system is failing?'
A: 'Yes.'
#JusticeForVeronicaNelson

Governor Jones is now being examined by counsel for the Department of Justice. After a few questions about documentation and training, Jones is asked about cultural awareness training specifically. #JusticeForVeronicaNelson

Governor Jones: 'Aboriginal cultural awareness training is done when they're in squad. We ran it quite regularly. All staff had refresher training in what cultural concerns are for Aboriginal people in our care and providing cultural support.'
#JusticeForVeronicaNelson

Governor Jones: 'We're also building an Aboriginal healing unit, and we've got some funding around that. We're going to build a unit that will house residentially Aboriginal women in there as part of the Stolen Generation and their healing. It'll be run by community Elders.'

Governor Jones: 'We've also got additional Aboriginal wellbeing officers now. We only had one Aboriginal wellbeing officer for years. We've now got three. We've got Aboriginal engagement advisors that are additional support for Aboriginal women that work in the [system].'

In response to questions from her own counsel: 'I will be taking steps to address a lot of the gaps that have articulated today that are of concern. Now that they've come to my attention I will be taking action because we can't have these happen again.' #JusticeForVeronicaNelson

Governor Jones has now concluded her evidence. The Court will now hear from Dr Foti Blaher, the Chief Medical Officer of Correct Care Australasia. Dr Blaher was given a certificate protecting him against self-incrimination in his evidence today. #JusticeForVeronicaNelson

Correct Care Australasia holds contracts for the provision of medical care to most prisons in Victoria.
Dr Foti Blaher notes: 'primary health care services.'
#JusticeForVeronicaNelson

Q: 'It's a contract that includes providing health care to 15 adult prisons in Victoria.'
A: 'I'd have to count and I can't say 15 accurately off the top of my head. I'm sorry.'
#JusticeForVeronicaNelson

Counsel Assisting: 'It's a contract to the tune of somewhere near about $70 million a year?'
Dr Blaher: 'I don't know. I'd be guessing.'
#JusticeForVeronicaNelson

Q: 'Now Correct Care's obligation under the contract is to provide health services.'
Dr Blaher: 'Yes, [...] in accordance with best practice [...] I don't know what exact quality standards we're held to within the contract.'
#JusticeForVeronicaNelson

Q: 'Well, Dr Blaher, you're responsible. It's your primary responsibility of you and the chief nursing officer to ensure the provision of quality health care and know as the standard of best practice it is that you are seeking to make.'
#JusticeForVeronicaNelson

A: 'Well, we work within the quality framework of Justice Health, and there are a number of standards within that which I would need to look up.'
Q: 'Isn't that something you need to know in order to do your job every day?'
#JusticeForVeronicaNelson

Q: 'It requires you to adopt a health outcomes approach, doesn't it?'
A: 'I think so. I believe so.'
Q: 'Have a positive impact on people's health?'
A: 'Yes.'
Q: 'Emphasis on improving the health of prisoners when under your care?'
A: 'Yes.'
#JusticeForVeronicaNelson

Counsel Assisting: 'And it also requires patients will be treated with compassion and respect, doesn't it?'
Dr Blaher: 'Yes.'
#JusticeForVeronicaNelson

Dr Blaher is asked what services CCA provided to DPFC around the time Veronica passed. He answers: medical assessments on reception, a doctor on site six days a week, a doctor on call after hours, nurses on site at all hours, administration staff, and other specialists as needed.

Q: 'Now effectively the services provided by the doctor and the nurses are a GP type service that's offered with extra Nursing and Allied Health attached to it?'
A: 'Yes, with the additional responsibilities of also supplying and providing medication.'
#JusticeForVeronicaNelson

Q: 'We've heard some evidence about nurses delivering that medication to cells at night or various times as part of their role?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'One of the one of the opinions that was given by the Medical Conclave was that the healthcare staff's skillsets require significant support and upskilling in DPFC, do you agree with that?'
A: 'I don't know if I would use higher degree.'
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Dr Blaher: 'It might be different degree and skill sets, slightly different to what one might need in suburban general practice.'
CA: 'The women that come into Dame Phyllis frost often have far more complex medical presentations. than they might in an ordinary general practice.'

Q: 'The women that come into DPFC often have far more complex medical presentations than they might see in an ordinary general practice?'
A: 'They might have, yes.'
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Q: 'Most patients in DPFS are likely to have all sorts of other challenges as well, by virtue of being in prison.'
A: 'What do you mean by other challenges?'
Q: 'Other emotional challenges, psychological challenges might be coming from places of trauma.'
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Q: 'It might require a greater set of skills than an ordinary GP practice?'
A: 'Yes, we do support our doctors in training regarding trauma-informed care, as well as our nursing staff, acknowledging that these are issues that one sees in prisons.'
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Counsel Assisting: 'Who's deciding on what level of supervision is required?'
A: 'It depends on their experience.'
Coroner: 'What is the maximum amount of supervision and orientation a completely new medical officer would receive?'
A: 'Up to 5 days.'
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Coroner: 'How much of those 5 days would be having another experienced doctor in the room?'
A: 'A day of observing. Maybe two days of having an experienced doctor observing.'
CA: 'You keep saying ‘it depends, it depends’. Is there not a minimum?'
A: 'It's around 3 days.'

Counsel Assisting: 'You say in your statement: 'Miss Nelson was accommodated in a custodial holding cell and not a medical ward.'
Dr Blaher: 'Yes, I believed that to be correct at the time I made the statement.'
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Counsel Assisting: 'Have you been into that medical centre, Dr Blaher?'
Dr Blaher: 'Yes, I have.'
CA: 'The unit that [Veronica] was staying in is labeled Ward Two. You will have seen that.'
A: 'I have seen that since writing that report.'
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Dr Blaher: 'They are cells which would never be considered, I would never consider them to be a hospital bed for medical treatment. You know, there's no oxygen. They might have the word Ward on the front of them, but we've not had them accredited.'
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Counsel Assisting: 'Ward Two, where Veronica spent the night, is not a place where prisoners can spend the night in order to receive medical treatment?'
Dr Blaher: 'Yes, I agree. It's not a place for medical treatment.'
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Counsel Assisting: 'You said earlier that Corrections Victoria use them for late admissions, protection from other prisoners, awaiting offsite transfer or health appointments. So all kinds of corrections-based reasons, not health reasons?
A: 'Yes, not medical health reasons.'

Counsel Assisting: 'That's not a location from which healthcare or whatever should be provided. Is that your position?'
Dr Blaher: 'Healthcare for someone who needs inpatient management should not be provided in those cells.'
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Q: 'What about care for patients whose medical presentation may not clearly be urgent enough for an emergency ward, but still require more than they would get in a locked cell?'
A: 'In DPFC, we can't provide overnight intense or moderate medical care.'
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Counsel Assisting: 'As an ordinary person, there are plenty of circumstances in which you feel pretty unwell. You don't take yourself to an emergency ward and instead have people around you take care of you, family or friends. They are of course in a prison environment.'

Counsel Assisting: 'You don't have family or friends assist you to keep a watch on you, to see if you are deteriorating. To check if you are vomiting up a lot, to see that you're getting enough fluids and enough vitamins into your system.' #JusticeForVeronicaNelson

Counsel Assisting: 'They're the sorts of things that people need, when they're unwell, but still might not appear sick enough to go to the emergency ward. How would those services be provided in DPFC in December 2019?' #JusticeForVeronicaNelson

Dr Blaher: 'We don't have the capability of providing the equivalent of family at the Dame Phyllis Frost Centre.'
#JusticeForVeronicaNelson

Dr Blaher: 'If we feel they're too unwell to be managed within a prison setting and within their own cells, then they should have further assessment in an in an appropriate facility such as a hospital emergency department.' #JusticeForVeronicaNelson

Q: 'As you say, because there aren't more family or friends around to check if a person is deteriorating — does that not increase the responsibility upon health care workers?'
A: 'It's their responsibility to assess that this person is not well enough to be in a cell.'

Dr Blaher: 'We do hundreds of assessments a week over many prisons. The default is that the person is well enough after the assessment. [...] Where a doctor identifies the person as unwell, that should trigger that further treatment is required.'
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Counsel Assisting: 'What I'm suggesting to you is that it shouldn't be the default in an environment where there is a particularly vulnerable group of women coming into a closed environment that we know often have very complex health presentations. Do you agree with that?'

Dr Blaher: 'I'm sorry, is the suggestion that most people are not well enough to go to their cells?'
Counsel Assisting: 'It's that it shouldn't be a default position, and it should be an active consideration of your doctors at the assessment stage.'
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Dr Blaher: 'There is a tick box in terms of accommodation, which can be used if the doctor feels that a different form of accommodation is required. And so it is I guess in that sense, an active decision.'
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Dr Blaher: 'We're not in the community. We are limited in the support they can have within the prison. If we're that concerned about a person's health, then I think they need further assessment. We would not be able to support that within the prison.'
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Counsel Assisting recounts numerous times Veronica is seen vomiting in evidence. 'Does she present as someone who's not well enough to be sent out to the mainstream prison at that point?'
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Dr Blaher: 'It's difficult for me to say. We now have the unfortunate benefit of hindsight in knowing that she did not respond to treatment. It's really difficult to for me to say should we have sent her to a hospital at that point.' #JusticeForVeronicaNelson

Dr Blaher: 'She would have been given the medication in the medical centre and there is the opportunity for that to be brought to our attention through the prison officers in the unit. She should not be completely abandoned within a prison cell.' #JusticeForVeronicaNelson

Counsel Assisting: 'I could tell you, doctor that there is every sense in which [Veronica] was completely abandoned in the prison cell.' #JusticeForVeronicaNelson

Counsel Assisting: 'In relation to the lowering of the threshold at which a patient will be sent out to hospital, is that something that's come about in response to the death of Veronica?'
Dr Blaher: 'We've certainly done that.'
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Q: 'Now Veronica passed away in custody after 4am. That was about 12 hours after being transferred out of the medical centre where she stayed under the care of medical staff.'
A: 'I didn't see any evidence to suggest that we provided her with any care over the first night.'

Counsel Assisting: 'Well, no, there wasn't much care over that night at all. We are in agreement on that.' #JusticeForVeronicaNelson

Q: '[Veronica] was attended to by your doctors on two occasions, seen by your nurses. Your doctor made a plan for further treatment. Do you still say that she wasn't under the care of medical staff?'
A: 'She was not receiving medical treatment whilst she was there overnight.'

Dr Blaher: 'There was no evidence that any of our staff conducted any observations on her after she had her medication. That's what I'm saying about that night.' #JusticeForVeronicaNelson

Counsel Assisting: 'Now, the Medical Conclave found that Veronica's death was preventable. My question to you is what level of responsibility do you on behalf of your company take for that preventable death?' #JusticeForVeronicaNelson

Dr Blaher: 'We are one component of the care that was provided — we were the medical aspect, but there are other players in terms of observing the situation and passing on information between custodial and health.' #JusticeForVeronicaNelson

Dr Blaher: 'The question is, someone else might be responsible for information and that information will contribute to our clinicians making decisions and their assessments and other health services.' #JusticeForVeronicaNelson

Dr Blaher: 'It's not straightforward, in my view, in looking at this and saying that entire responsibility goes to one person, one party when this is a system wide issue. There are many points in time and people who are responsible for this lady's care.' #JusticeForVeronicaNelson

Counsel for Aunty Donna is now putting questions to Dr Blaher. 'Would you expect a doctor to turn their mind to whether it's safe to lock someone in a cell for twelve hours in a reception assessment?'
A: 'I would expect that's what they're considering.'
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Q: 'You’re the chief medical officer. Can you explain what that means in relation to clinical supervision of the doctors that CCA hire?'
A: 'I don’t provide direct supervision. I provide the credentialing of our doctors in terms of employment.'
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Counsel for Aunty Donna Nelson: 'Who provides the supervision then?'
Dr Blaher: 'There is little direct clinical supervision. That is why we employ GPs who are capable of providing primary care.'
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Q: 'Are you the boss of the senior medical officer?'
A: 'Yes.'
Q: 'So ultimately, accountability sits with you?'
A: 'Yes.'
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Counsel Assisting: 'How do you determine if someone is performing adequately, if you’re not providing supervision?'
Dr Blaher: 'We have a service that doctors, nurses and health services managers and they report back in terms of care their patients are receiving.'

Q: 'We heard evidence that [Ms Hill] had concerns about the care a doctor was providing. What did you do in that case?'
A: 'Well, she did not provide that concern. I am unaware if she provided that info about his clinical practice to her supervisor.'
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Counsel for Aunty Donna Nelson: 'A doctor is only supervised if a problem is raised?'
Dr Blaher: 'Yes.'
Q: 'So it's reactive, rather than proactive?'
A: 'Yes.'
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Q: 'In your statement to the Coroner, you said the decision for Veronica to stay in the medical centre overnight was not made by CCA staff. On day 2 of the inquest you clarified that saying you are now unable to say with certainty.'
A: 'That’s correct.'
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Q: 'Why are you now uncertain?'
A: 'I was informed that Ms Hills has made statement saying she made that decision.'
Q: 'She was CCA staff?'
A: 'Yes.'
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Q: 'You’ve said, and we don’t disagree, that the medical centre is not a good place to stay overnight. You’d have to agree that the very name ‘medical centre’ gives rise to an impression of where sick people go?'
A: 'Well, not inpatient treatment.'
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Q: 'You know surely that people do stay overnight there?'
A: 'I now know that has been a practice.'
Q: 'When did you first become aware that was a practice?'
A: 'I don’t know.'
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Q: 'I understood from your evidence that you don’t provide supervision.'
A: 'I don’t provide direct supervision on site. I also do performance check annually, but in the sense of medical supervision, sitting next to them, I do not provide that.'
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With that, the Coroners' Court has adjourned until 9am tomorrow morning. This will be the final day of the inquest. If you can, show your support in person. #JusticeForVeronicaNelson

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