Thread by @dhadjowa

It's the final day of the inquest into Veronica Nelson's death in custody. We'll hear from Dr Foti Blaher and Christine Fuller, Chief Medical and Nursing Officers of Correct Care Australasia.
If you can, come to the Coroners' Court to show your support. #JusticeForVeronicaNelson

Some details for those who haven't attended the Victorian Coroners' Court before — it's at 65 Kavanagh Street, Southbank. Masks are required to enter the Court, and there is a security screening process.
Public transport and parking details here: coronerscourt.vic.gov.au/contact-us

If you can't make today's hearing in person, please listen in at this link. #JusticeForVeronicaNelson csvic.webex.com/mw3300/mywebex…

Court has commenced this morning, one hour earlier than usual to accommodate the volume of evidence to be heard. Aunty Donna Nelson's counsel continues her questions to Dr Foti Blaher. #JusticeForVeronicaNelson

Examination now on the forms used to assess and document Veronica's health.
Q: 'So, it's very hard to know if there is an accurate account of examination and history or if [doctors] simply used the shortcut?'
A: 'The expectation is that a proper clinical assessment is conducted.'

Counsel for Aunty Donna Nelson: 'You’d agree, then, that his notes do not reflect a proper clinical assessent.'
Dr Blaher: 'Yes, I do agree that his notes didn’t reflect his assessment at the time.'
#JusticeForVeronicaNelson

Q: 'So, you could see from looking at the fields [on the form] very shortly after Veronica’s passing that the notes were quite inaccurate?'
A: 'Yes.'
#JusticeForVeronicaNelson

Counsel for Aunty Donna Nelson: 'What did you do about that? Did you let Justice Health know that the notes appeared to be almost without exception [just] the template?'
Blaher: 'Not without exception, he did-'
Q: 'There were two changes?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'Did you tell Justice Health, knowing that they would be conducting a review into Veronica’s passing?'
A: 'I can’t recall if i specifically told them that.'
Q: 'Do you think it’s more likely you didn’t?'
A: 'I can’t recall.'
#JusticeForVeronicaNelson

Dr Blaher: 'I did have conversations with Justice Health. I can’t recall if I spoke specifically about this document and the language I spoke about it with, I just can’t recall.'
#JusticeForVeronicaNelson

Q: 'I suggest this template encourages or excuses poor clinical practice. It takes the onus away from the doctor to write in their notes their findings and examinations.'
A: 'It provides a template in which doctors [...] should write the appropriate clinical information.'

Q: 'Did you instruct [the doctor who saw Veronica] that he needed to improve his practice when you reviewed his notes?'
A: 'Yes.'
Q: 'When you spoke to [the doctor], did he remember seeing Veronica?'
A: 'I can’t recall.'
#JusticeForVeronicaNelson

Q: 'You’d remember patients within a week, wouldn't you?'
Dr Blaher: 'Normally, but not necessarily, I would need reminding if I had seen 20 patients on a day. A week or two later, I would need the notes.'
#JusticeForVeronicaNelson

Q: 'As the medical director, you'd know that an important part of care is analysing serious adverse incidents for root causes, so prevention opportunities can be identified.'
A: 'Yes.'
Q: 'CCA didn’t conduct any root cause analysis?'
A: 'Not specifically ourselves.'

Q: 'You do know that, as the health service provider, you are required to do a root cause analysis for serious events?'
A: 'I was informed that our policy was not to conduct an initial review or root cause analysis until there was the external review.'
#JusticeForVeronicaNelson

Q: 'I want to suggest to you that [not doing a root cause analysis] is in breach of Justice Health frameworks. You're the medical director — you don’t have a view on whether there was a breach?'
Dr Blaher: 'I’d need to review the contract.'
#JusticeForVeronicaNelson

Q: 'As a matter of policy, you just didn’t do it?'
A: 'We didn’t do it immediately, no.'
Q: 'Did you do it at all? I am asking about your obligations. Did you at any time conduct a review into Veronica's passing?'
A: 'We did not conduct a formal review.'
#JusticeForVeronicaNelson

Q: 'What about Correct Care Australasia? Was there any other review, formal or otherwise, undertaken by CCA?'
A: 'The regional manager gathered statements, but my understanding was that we didn’t conduct a formal review.'
#JusticeForVeronicaNelson

Q: 'Did you read the statements?'
A: 'Yes.'
Q: 'So you would have known that there was a lot of information in those statements that was not in clinical records?'
A: 'Yes.'
Q: 'Did you let Justice Health know?'
A: 'No.'
#JusticeForVeronicaNelson

Q: 'You’d agree that if Justice Health only looks at medical records, and doesn’t have benefit of statements that CCA obtained, that review would be deficient?'
A: 'If that was all that they based their review on, yes.'
#JusticeForVeronicaNelson

Counsel for Aunty Donna Nelson: 'What I want to suggest to you is that CCA had information it knew did not paint it in a good light. It had information it knew that Justice Health didn't have, and it then hid behind the report which said nothing went wrong.'
Blaher: 'I disagree.'

A question now from the Coroner: 'It wasn’t an accident that you didn’t give [this information] to Justice Health?'
Dr Blaher: 'I don’t recall whether a conscious effort was made not to. We collected statements for the purposes of the coronial inquest.'
#JusticeForVeronicaNelson

Q: 'Do you acknowledge that the care provided by Dr Runcares & Dr Brown had serious deficiencies?'
A: 'I guess we know the outcome & the unfortunate passing of Veronica, so we can say that there were opportunities not identified in those assessments.'
#JusticeForVeronicaNelson

Aunty Donna Nelson's counsel continues (after posing the question above) by raising that the expert Medical Conclave 'concluded unanimously that treatment provided was deficient, not missed opportunities.'
A: 'I acknowledge that there were deficiencies in their assessments.'

Dr Blaher: 'If things were done differently, we may have had a different outcome.'
Q: 'Why now, at the end of a 5 week inquest, do you acknowledge this? What changed?'
A: 'Different information has now been provided through the course of this hearing.'
#JusticeForVeronicaNelson

Q: 'The submission that Aunty Donna will make is that Correct Care Australasia is involved in a continued cover-up regarding medical care provided to prisoners at DPFC, specifically Veronica. Do you have a response to that?'
Dr Blaher: 'I disagree.'
#JusticeForVeronicaNelson

Blaher is now being examined by counsel for Uncle Percy Lovett.
Q: 'The CCA page describes you as having 'primary responsibility, with the CNO, to ensure the provision of quality care to our patients within the correctional environment'. Would you agree with that?'
A: 'Yes.'

Q: 'You agree that in a prison setting there are risks of bias and systemic racism that persist. The risks are there, do you agree?'
Dr Blaher: 'I guess it’s a similar risk as one would see in the community.'
#JusticeForVeronicaNelson

Q: 'You’re aware of the risks of Indigenous people dying in custody, compared to non-Indigenous people?'
A: 'Yes, I am well aware of that.'
Dr Blaher then outlines some of his experience in working with Victoria Police.
#JusticeForVeronicaNelson

Q: 'I looked through CCA policy on Aboriginal and Torres Strait Islander health. They don't mention systemic racism or the risk of Indigenous people dying in prison. Are you aware of any policies that address these issues?'
A: 'I can’t recall.'
#JusticeForVeronicaNelson

Q: 'Do Correct Care Australasia staff receive training in relation to the Human Rights Charter?'
Dr Blaher: 'To my knowledge, I don’t recall.'
#JusticeForVeronicaNelson

Q: 'Correct Care is captured by the Human Rights Charter because you are a public authority. Is that something you are aware of?'
A: 'I couldn’t answer that confidently.'
#JusticeForVeronicaNelson

Q: 'You simply don’t know that Correct Care is bound by the Human Rights Charter?'
A: 'I expect that we are, but I can’t tell you definitively. I expect that we are and should be.'
#JusticeForVeronicaNelson

Q: 'Do you agree that if Correct Care is bound by the Human Rights Charter, that requires that Correct Care acts compatibly with the Human Rights Charter?'
A: 'Yes.'
#JusticeForVeronicaNelson

A final question from Uncle Percy Lovett's counsel: 'So you would agree that it’s fundamental that Correct Care Australasia doctors and nurses receive training on the Charter?'
A: 'Yes, they could have some training on it.'
#JusticeForVeronicaNelson

Questions now from Dr Brown's counsel, on evidence heard earlier that some nurses had not taken observations. 'You’d agree, having reviewed this case, that was an important set of observations that was not done?'
Dr Blaher: 'I agree it was important that they be carried out.'

Dr Blaher is now taking questions from Counsel for Correct Care Australasia.
Q: 'How would it benefit the women inside if DPFC had specialist practitioners?'
A: 'I would welcome any in-reach specialist service. This is more for Justice Health, we would [only] be the conduit.'

Q: 'Is it your expectation that if medical issues arise subsequent to assessment, that a medical officer would be informed about such issues?'
A: 'Yes, by the nursing staff if it is a required intervention in any way.'
#JusticeForVeronicaNelson

Q: 'There has been quite a bit of evidence about women experiencing withdrawal upon entering DPFC — what can you tell His Honour about this?'
A: 'I don’t have definite numbers in terms of withdrawal, it’s certainly something that’s a significant issue.'
#JusticeForVeronicaNelson

Q: 'Do women at DPFC have access to AOD support services?'
A: 'They do through [another service] and access to counselling. We don’t have access to their notes.'
#JusticeForVeronicaNelson

Q: 'Does Correct Care Australasia provide any opportunities for med practitioners to undertake any other training [in relation to addiction medicine]?'
A: 'Yes, we provide them with opportunities.'
#JusticeForVeronicaNelson

Questioning has moved to CCA talks with Justice Health to change the templates doctors and nurses use.
The Court hears that the changes are to structure the form with headings rather than pre-filled options.
'It’s probably taken longer than it should to develop [due to COVID].'

Dr Foti Blaher has now been excused and his evidence is complete. 'If I could conclude by passing on my sympathies and sorrows to the family and friends of Ms Nelson on the terrible circumstances of her passing.' #JusticeForVeronicaNelson

The Court will now hear from the final witness — Christine Fuller. Fuller is Chief Nursing Officer of Correct Care Australasia. She has been reminded that the certificate protecting her from self-incrimination applies to her evidence today. #JusticeForVeronicaNelson

Counsel Assisting: 'As the Chief Nursing Officer of CCA, you together with the Chief Medical Officer [Dr Blaher] have primary responsibility for the provision of quality healthcare at DPFC?'
Fuller: 'That’s right.'
#JusticeForVeronicaNelson

Q: 'Between the two of you, you have responsibility for ensuring that CCA meets the expectations of quality imposed by contract with the Victorian Government?'
A: 'Yes.'
Q: '-and through that relevant government health policies?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'The current contract is worth about $70 million per year to CCA?'
A: 'Approximately, yes.'
Q: 'And there's also a further contract to the Victorian Government for youth justice facilities?'
A: 'That’s right, yes.'
#JusticeForVeronicaNelson

Counsel Assisting: 'Is it your position that Correct Care Australasia sometimes does conduct root cause analysis to events?'
Fuller: 'To events, not to deaths in custody.'
#JusticeForVeronicaNelson

Fuller: 'The practice hasn’t been to do a root cause analysis for deaths in custody because Justice Health do their own review. If anything comes out of the debrief [...] that’s obvious and clear and that we can make improvement on, we will.'
#JusticeForVeronicaNelson

Fuller: 'For example, there has been a lot of discussion on the lack of clarity in holding cells between Corrections and CCA [after Veronica's passing]. There has been a significant piece of work done on this over the last two years at a high level.' #JusticeForVeronicaNelson

Counsel Assisting: 'We heard evidence during this inquest, where the communications were played following the Code Black that was called when Veronica’s body was found. Was that an awkward bit of audio to listen to?'
Fuller: 'Yes.'
#JusticeForVeronicaNelson

Fuller: 'What we heard was a great difficulty for corrections staff, or indeed any staff who are responding to the Code Black, to be able to get in contact or to provide communication between emergency services and someone close to Veronica.'
#JusticeForVeronicaNelson

Counsel Assisting: 'Now in terms of second issue, the holding cells issue, you say that a conversation has been going on for over two years now?'
Fuller: 'Yes.'
Q: '[Did that arise] out of Veronica's passing?'
A: 'No, it's been happening a long time.'
#JusticeForVeronicaNelson

Fuller: 'There is a lack of clarity. And I think we've heard a lot of evidence around the name of the cells, the wards, they're called medical beds. There's just a lot of grayness around who's responsible for what and it's not well integrated.'
#JusticeForVeronicaNelson

Counsel Assisting: 'Is it the case that this still hasn't been resolved?'
Fuller: 'We've done an extensive piece of work with CCA, Justice Health, Corrections and Forensic Care to look at the types of observations that prisoners are provided with [...] in holding cells.'

Fuller: 'The beds in DPFC are actually holding cells, not medical beds. The intercom goes to a Corrections Officer post and not to nursing. It’s not appropriate and we are trying to clarify who is responsible for what.'
#JusticeForVeronicaNelson

Counsel Assisting: 'It has taken over two years for policy change. Do you say that it's being laboured by the fact that there are two organisations (CCA and Corrections) that have to be changed?'
A: 'It's the complexity of providing healthcare in a correctional setting.'

Q: 'The problems you identified with the blurriness around the holding cell or ward and what services could be provided — you accept that this was relevant to the failing in care in relation to Veronica’s stay?'
A: 'Yes, I do.'
#JusticeForVeronicaNelson

Q: 'When [Veronica] spent the night, she received a decided lack of care for someone who was placed there because of her ill health?'
A: 'I'd like to explain. There was poor documentation, communication and handover between the people that decided and who were caring for her.'

Q: 'Do you say that [two years] is an acceptable timeframe in which to resolve an issue like that, that was central to the lack of care provided to Veronica?'
Fuller: 'No, it's not appropriate, but it's not within my control.'
#JusticeForVeronicaNelson

Q: 'I want to go back to the review process and what has been learnt about this. I understand your position is that there was no root cause analysis or internal review undertaken in relation to Veronica's passing?'
Fuller: 'Correct.'
#JusticeForVeronicaNelson

Q: 'We have evidence before the Coroner that there were two CCA employees to source and review information about what had occurred in relation to Veronica’s stay.'
Fuller: 'The regional manager was asked to obtain statements from staff for inquest. That is our usual process.'

Q: '[That CCA employee] described it as 'interviewing all CCA staff involved in the case [...] to develop a timeline of events, provide post-incident support and identify points of improvement'.
Fuller: 'I did not task him with undertaking that review.'
#JusticeForVeronicaNelson

Fuller: 'I asked [the staff member] to get statements and to attend the site and act in support of staff in relation to the death of Veronica.'
Q: So you say that is incorrect? Those were not tasks provided by CCA?'
A: 'It may be his interpretation.'
#JusticeForVeronicaNelson

Q: 'But you say, beyond providing support and asking them to sit down and write the statement, he didn’t have any other role in addressing ongoing quality or improvement planing? Or providing information for that purpose?'
A: 'No, we do that with Justice Health.'

Q: 'When a prisoner dies of ill health do you not make inquiries of your own staff directly as to whether or not that could have been avoided? Or whether or not things could change so it doesn't happen again?'
A: 'Not at that time we don’t.'
#JusticeForVeronicaNelson

Fuller: 'We wouldn't have known cause of death for Veronica, so there is information that we need. If there is information that comes out in that review or in discussion or debrief, we would act on that.'
#JusticeForVeronicaNelson

Q: 'You did know that [Veronica] hadn’t been assaulted. She was alone in a cell. You knew that she had been unwell before then.'
A: 'It turns out there’s a lot of unknowns, we wouldn’t have known if it hadn't been investigated by Corrections and JARO.'
#JusticeForVeronicaNelson

Fuller: '[Unknowns like] the intercom. We didn’t know who made the decision to hold her in the cell. So no, I didn’t have that information.'
#JusticeForVeronicaNelson

Q: 'You didn’t provide [statements from CCA staff] to Justice Health or JARO?'
Fuller: 'It’s not a normal process to do that, no.'
Q: 'That wasn’t the question. You didn’t provide them.'
A: 'No, we didn’t. It’s not normal process to do that.'
#JusticeForVeronicaNelson

Q: 'Now in those statements there was information that was suggestive of failings or weaknesses in system of healthcare available to Veronica at that time.'
A: 'Could you give an example?'
#JusticeForVeronicaNelson

Q: 'Sure, I could give you a few. You were aware quite early on there was documentation deficiencies in relation to the care provided to Veronica.'
A: 'Can you be a bit more specific?'
#JusticeForVeronicaNelson

Q: 'You also were aware the risk rating [on file] had been upgraded the morning after Veronica had died.'
A: 'Yes, the nurse went in and added a care plan for Veronica. I believe she felt that she should do that because it hadn't been entered.'
#JusticeForVeronicaNelson

Fuller: 'There was a lot of discussion with Justice Health about that. It's not a situation where you want people going into a file and adding things. But she went in and added it as she felt it was missed.'
#JusticeForVeronicaNelson

Q: 'The reason why that had occurred was?'
A: 'The nurses hadn’t included it. When people have a chronic disease they need a M2 rating and a care plan.'
Q: 'Was anything else added later to documentary info?'
A: 'You can audit the file to see what’s been added at any one time.'

Q: 'Nurse Hills provided evidence that she offered to provide a statement [...] & effectively no statement was pursued from her. [We heard] that she was concerned about Veronica's state of health & felt she needed to be transferred to hospital.'
A: 'I have no evidence of that.'

Q: '[The staff collecting statements] said there was a preference expressed by executive management not to collect a statement by Nurse Hills, is that right?'
A: 'No.'
Q: 'At the time you were part of the executive of CCA?
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'You were engaged in communications with the relevant authorities?'
A: 'Yes.'
Q: 'You say do you that that just did not occur?'
A: 'It did not occur.'
#JusticeForVeronicaNelson

Q: '[The staff member who took statements] says another thing he identified in his review of Veronica's passing was an absence of a process for escalating prisoners who were deemed unwell who didn't need a Code Black.'
A: 'I don’t agree with it from a health perspective.'

Q: 'There is not a clear line of when an ambulance should be called. There are shades of unwellness, do you agree with that?'
A: 'No not in a primary healthcare setting. It’s difficult at DPFC. We don’t monitor patients overnight, as such. We might do follow up review overnight.'

Fuller: '[T]hat might determine the next treatment plan, but we aren't in a position where we are able to monitor patients overnight, particularly if they are in a unit.'
#JusticeForVeronicaNelson

Q: 'Sometimes, do you accept, patients just need to be watched before a call is made about whether they ought to be sent to a cell or to hospital?'
A: 'Which is what happens. Corrections staff are the ones who do observations.'
#JusticeForVeronicaNelson

Fuller: 'We don’t have the area or staffing model to be able to monitor patients overnight at DPFC.' #JusticeForVeronicaNelson

Q: 'The proposition I am putting to you to accept is that there is quite a range of health presentation that lies in between of those two states [total wellness and requiring urgent hospitalisation]. Do you accept that?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'In terms of Veronica’s condition, do you accept that she ought to have been sent out to hospital within an hour or two of her having arrived into the Dame Phyllis Frost medical centre?'
A: 'I wasn’t there. It’s based on clinical judgement.'
#JusticeForVeronicaNelson

Q: 'Thank you, but that wasn’t the question. Do you accept that Veronica should have been sent out to hospital within an hour or two of her having arrived into the Dame Phyllis Frost medical centre?'
A: 'Based on clinical assessment undertaken by clinicians at the time: no.'

Q: 'You have heard five weeks of evidence. You have heard from medical experts. I am inviting you to directly answer my question based on what you now know as Deputy CEO of CCA.'
A: 'It’s hard to say. I think probably when she continued vomiting, which was the next day.'

Q: 'Is it a requirement of the contract that CCA has with the government that they must fully cooperate with any investigation?'
A: 'Yes.'
Q: 'And that includes making all relevant records, reports and other documents available?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'If CCA does not conduct internal investigations in response to a death in custody, if you rely solely on [external investigations], is it not particularly integral to a fair and thorough review process that CCA makes all records, reports and documents available?'
A: 'Yes.'

Q: 'The CCA DPFC rosters were not provided to Justice Health's review.'
A: 'They weren’t asked for. If they were asked for, we would have provided them.'
Q: 'Well, they are under the contract.'
#JusticeForVeronicaNelson

Q: 'When you say they had access to your staff, it’s hard for them to know which staff to contact without the rosters, isn’t it?'
Fuller: 'If they asked for the rosters, we would have provided them.'
#JusticeForVeronicaNelson

Q: 'Did you provide to JARO or Justice Health the information that [CCA staff] had been obtaining in those statements promptly after Veronica's passing?'
A: 'I didn’t have any review from [the CCA staff member].'
#JusticeForVeronicaNelson

Q: 'No, the question was: did you provide information about the fact that someone from your company was looking in to [Veronica's] passing? Did you pass that on?'
A: 'I didn’t have any information to pass on. He wasn't asked to investigate. He was asked to request statements.'

Q: 'You knew he was gathering statements, did you tell them that?'
A: 'I wasn't asked, and our normal process is to get statements. I wasn’t hiding anything.'
Coroner: 'So, they didn't ask and you didn’t tell them?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'Is that the consistent-'
A: 'No.'
Q: '-approach you take to a review undertaken by JARO-'
A: 'No.'
Q: '-or Justice Health?'
A: 'No, I don't.'
#JusticeForVeronicaNelson

Fuller: 'It wasn’t different, there is a discussion to be had and if there is something that I think will be helpful to the review it will be provided.' #JusticeForVeronicaNelson

Q: 'Is it the case CCA did not provide to Justice Health any statement or concession that was being made on the role of CCA leading up to the passing of Veronica?'
A: 'I don’t believe we did. [...] Justice Health don’t ask us what we are presenting for an inquest.'

Q: 'So, this inquest has heard a number of direct concessions made by CCA staff about failings in the care they provided to Veronica. Do you accept that?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'It’s the case, isn’t it, that CCA is waiting for the review to know what it has to do to change and improve?'
A: 'At a basic level, yes.'
#JusticeForVeronicaNelson

Q: 'And yet, Justice Health and JARO don’t have all of the information that you have when they are conducting those reviews?'
A: 'Such as?'
Q: 'CCA's statements, for example.'
A: 'No, they don't.'
#JusticeForVeronicaNelson

Q: '[The staff member collecting statements] was armed with the earliest available information from staff about Veronica’s care, wasn’t he?'
A: 'If you mean in the form of statements-'
Q: 'I mean the information. He had a picture as to what had gone on.'
A: 'I don’t know.'

Fuller: 'He wasn’t tasked with doing that. He didn’t give me any sort of report. He could have been interviewed to provide the information.'
Q: 'Only if Justice Health and JARO knew he existed and what information he holds.'
A: 'They know he exists.'
#JusticeForVeronicaNelson

Fuller: 'They know the process by which we participate in this review. If we had information that we thought was useful, we would provide it.'
#JusticeForVeronicaNelson

Q: 'A statement was provided from every CCA staff member who had contact with Veronica while she was at DPFC, expect for Nurse Hills.'
A: 'What we do is look at the roster and who has been involved, and I think it wasn't clear-'
Q: 'She was rostered on.'
#JusticeForVeronicaNelson

Fuller: 'It wasn’t clear that she was involved in the care of Veronica.'
Counsel Assisting: 'Ms Fuller, that is hard to imagine given that it was her that signed the medical reception document.'
#JusticeForVeronicaNelson

Fuller: 'I am just saying that I think it became more apparent over time that she was involved and required a statement. It’s not a matter of us trying to cover up someone who should be making a statement. It’s about trying to work out who is involved.'
#JusticeForVeronicaNelson

Q: 'Nurse Hills signed a medical reception document. Nurse Hills said she offered to provide a statement and that she had problems with Veronica not being sent to hospital. And we have [a staff member's] statement saying that CCA executives asked him not to take her statement.'

Counsel Assisting: 'And, we have statements from everyone but Nurse Hills. Do you maintain your position that there was never a directive that a statement from Nurse Hills be avoided?'
Fuller: 'Yes, I do.'
#JusticeForVeronicaNelson

Q: 'In the OPCAT review conducted in 2017, 45% of [people inside] reported health services as very bad and 20% reported it as bad. We have also heard from Governor Jones that the level of criticism of healthcare has only increased since then. Do you accept the findings?
A: 'Yes.'

Counsel Assisting: 'Do you accept the evidence given by Governor Jones that in fact it has been reported that the services have deteriorated since then, rather than improve?'
A: 'Not globally, no.'
#JusticeForVeronicaNelson

Q: 'Do you accept that there is a need to respond to these criticisms?'
A: 'So, we have a governance process in place. We have a contract. We have KPIs and SDOs, we have a process for any feedback and communications — from patients, staff, executives.'
#JusticeForVeronicaNelson

Q: 'Do you accept that there is a lot more work to do there for your organisation, to improve quality of care?'
A: 'We are in a continuous improvement cycle and we have a quality control program, independent accreditation and a process to review incidents to make improvement.'

Q: 'Do you accept that the process hasn’t been working?'
A: 'No, I don't.'
Q: 'Do-'
A: 'No, I don't.'
Q: 'Do you accept that the process failed Veronica?'
A: 'I do.'
#JusticeForVeronicaNelson

Q: 'Are you able to articulate in what ways the system failed Veronica?'
Fuller lists the 'difficulty in providing good accommodation', 'poor documentation and handover between clinicians', and a lack of 'integration' between Corrections and CCA.
#JusticeForVeronicaNelson

Q: 'We heard from Governor Jones about lost faith in the care provided by CCA at Dame Phyllis Frost. Do you accept that once clients of a health service have lost faith, it's difficult to provide healthcare?'
A: 'I don't have evidence that the patients have lost faith.'

Fuller: 'We have been working closely with Aboriginal patients at DPFC to listen closely to what their needs are. We have always participated in the patient feedback groups.'
#JusticeForVeronicaNelson

Q: 'The expert Medical Conclave provided evidence that it seemed to be a punitive form of healthcare that's offered at DPFS. Do you accept at the time Veronica was there that there was a punitive approach to healthcare?'
A: 'No, I don’t believe so.'
#JusticeForVeronicaNelson

Fuller: 'Our vision, which was created by our staff a few years ago, is — healthcare without judgement. That means we are there to provide healthcare and we aren't there to judge or disrespect people because they are in prison.'
#JusticeForVeronicaNelson

Fuller: 'We work in a unique environment and there’s barriers. The Medical Experts had a very hospital and emergency lens and didn’t appreciate some of the barriers in a custodial setting. It’s not punitive, but there are some restrictions.'
#JusticeForVeronicaNelson

Counsel Assisting: 'You are saying, presumably in terms of the care Veronica was provided, that it wasn’t punitive in nature. Is that right?'
Fuller: 'Punitive from the clinical staff? In what sense?'
Q: '[Her] treatment when she opened her hand to get panadol through the trap.'

Q: 'Or the fact she didn’t receive any follow up treatment on the 31st.'
A: 'I think we have made some concessions about what we missed.'
Q: 'Looking at all the things together, I am suggesting to you — her healthcare was approached punitively.'
A: 'I don't accept that.'

Counsel Assisting: 'Do you accept that the service she did receive was something less than equivalent to what she would have received in the community?'
Fuller: 'No. It wasn’t made intentionally and it wasn’t done because she was in prison.'
#JusticeForVeronicaNelson

Counsel Assisting: 'The question is specifically not about the intention of you or others, but about the quality of care that she received. Do you accept that it was not equivalent to the quality of care that she could have received in the community?'
Fuller: 'Ah, yes.'

Counsel Assisting: 'It’s been 30 years since RCAIDC. In that time, has CCA's 'continuous improvement cycle' made any progress in relation to Aboriginal deaths in custody?'
Fuller: 'We continue to review our systems and processes to try and make improvements wherever possible.'

Fuller: 'I suppose as the incarceration rate continues to rise and Aboriginal people continue to be over represented, the numbers haven’t reduced. But, we are always looking for ways to improve our systems and processes for all our patients.'
#JusticeForVeronicaNelson

Fuller: 'We have commitments to improve the healthcare of Aboriginal patients. We have partnered with Aboriginal health providers. At DPFC is pap smear clinic run by VAHS. That’s a collaboration to provide culturally competent care to our women.'
#JusticeForVeronicaNelson

Fuller: 'We work with Rumbalara on dental services for other prisons. We are increasing our Aboriginal healthcare workforce. We have done a lot of work on scholarships to have Aboriginal people become nurses.' #JusticeForVeronicaNelson

Q: 'The question was about whether your organisation is able to point to any reduction in the rate of Aboriginal deaths in custody of the service you operate.'
Fuller: 'No.'
Q: 'How many Aboriginal women have died in custody at DPFC since Veronica's passing?
Fuller: 'Two.'

Fuller: 'We have policies to provide healthcare and to minimise risk.'
Q: 'But they are not working, are they?'
A: 'Well no, deaths in custody are increasing for everyone. If we knew the answer to reducing it, all of us would be doing it.'
#JusticeForVeronicaNelson

Counsel Assisting: 'Do you think, Ms Fuller, if you had undertaken a review into Veronica's death immediately after it had occurred, it might have reduced the likelihood of those two women dying in custody?'
Fuller: 'It may have.'
#JusticeForVeronicaNelson

Counsel Assisting: 'Correct Care Australasia is a company that has a primary duty to its shareholders is that right?'
Fuller: 'Yes.'
Q: 'A company that is run for profit?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'A contract that is worth about $70 million a year?'
Fuller: 'That’s the cost of the contract, that’s not the profit.'
Q: 'Is there a conflict between providing the very best care available and providing a profit for your shareholders?'
A: 'No.'
#JusticeForVeronicaNelson

Counsel Assisting poses one last question to Christine Fuller, Deputy CEO of Correct Care Australasia.
Q: 'You’d be soon entering into negotiations for a new contract, due to start next year?'
A: 'No. It’s out for tender at the moment.'
The Court breaks for lunch.

The Court has resumed. Christine Fuller, Deputy CEO of CCA is now taking questions from counsel for Uncle Percy Lovett.
He asks about whether CCA nurses and doctors are trained to meet the complex needs of prisoners.
'There is access to specialist advice, but yes.'

Counsel for Uncle Percy Lovett goes through the training of CCA doctors who have given evidence to the inquest so far.
'They've got medical degrees, but not necessarily general practice specialisations?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'The submission that Uncle Percy will make is that because a person in the community can go and see a GP, that women within prisons should also have that similar access to qualified GPs. This has support from the Medical Conclave. Do you agree?'
A: 'Yes.'

Fuller: 'I think some of the difficulty is around access to the workforce. It might be difficult to find enough people with general practice specialisation, but it's preferable.'
#JusticeForVeronicaNelson

Q: 'Given every one of those medical staff were deficient [according to the Conclave], do you think that indicates a systemic issue?'
A: 'That's unclear, they were only looking at Veronica’s case.'
#JusticeForVeronicaNelson

Q: 'You would defer to their view that Veronica in fact needed to got to hospital when she presented at the prison with a BMI of 13.'
A: 'Um, [in hindsight] yes.'
#JusticeForVeronicaNelson

Q: 'You were asked earlier about the way CCA is structured. Now, its parent company is a company called Wellpath, from Nashville Tennesse, is that correct?'
Fuller: 'Yes.'
Q: 'One of the largest for profit health care providers in the US?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'Wellpath provides healthcare to prisons around the world?'
A: 'Yes.'
Q: 'As I understand, the initial contract here was $549 million for 11 years, with a top up of $70 million. The youth justice contract has a value of $49 million.'
A: 'That's the cost, not the profit.'

Q: 'You were asked questions earlier about CCA's lack of root cause analysis. [Uncle Percy] will likely submit that CCA’s conduct in failing to investigate was simply a deliberate cover-up to ensure it could hold on to these lucrative contracts. Do you accept that?'
Fuller: 'No.'

The Court is now hearing questions from counsel for Aunty Donna Nelson.
Q: 'What’s the reason that CCA relies on Justice Health for reviews on a death in custody?'
A: 'Because they have access to custodial information. We don't have all the information.'
#JusticeForVeronicaNelson

Q: 'But Justice Health looks at medical care provided?'
A: 'They do.'
Q: 'And you provide the care. So it would be logical that you would be the ones who conduct the review?'
A: 'Justice Health is more independent, otherwise we are reviewing ourselves.'
#JusticeForVeronicaNelson

Q: 'Do you think the desktop review here was more objective and informed than a review that could have been conducive by CCA?'
A: 'Probably not.'
#JusticeForVeronicaNelson

Q: 'The Justice Health framework for the provision of healthcare in prisons puts an obligation on the provider of healthcare services to conduct a review. That's you?'
A: 'Yes, it is.'
Q: 'Your contract obliges you to comply?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'For as long as you’ve been with Correct Care Australasia, you haven’t been complying with your contractual obligation?'
A: 'There was a decision that we will not undertake a review of a death in custody.'
#JusticeForVeronicaNelson

Counsel for Aunty Donna outlines reporting structures within CCA.
Q: 'So, when there was this awareness of a death in custody and knowledge a review was undertaken, [staff who took statements] would have been at that meeting?'
A: 'I believe so, yes.'
#JusticeForVeronicaNelson

Q: 'He would have been well aware that a review was being conducted into Veronica’s passing?'
A: 'By Justice Health?'
Q: 'Any review at all? I’m asking generally. He would have been well aware that someone was going to?'
A: 'He would have been aware.'
#JusticeForVeronicaNelson

Counsel for Aunty Donna puts to Christine Fuller: 'The purpose [of CCA's review] wasn’t quality improvement. It was about viewing Veronica’s passing as a legal problem.'
A: 'It was to support the staff and to draft the statements while their memory was closer to the event.'

Q: 'But these statements weren't provided to Justice Health.'
A: 'That's right.'
Q: 'So, the problem is you saw it as part of the legal process, rather than part of the patient safety process?'
A: 'No.'
#JusticeForVeronicaNelson

Q: '[A nurse's] statement identified that there had been a planned review but he didn’t do it. That would be opportunity for [patient safety] improvement?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'That wasn't raised at debrief or with Justice Health. The first time it came out is by concessions of your legal team two weeks before this inquest. Why didn’t you tell the inquest this [before]?
A: 'It was in my statement. It was discussed at clinical governance.'

Q: '[The nurse] identifies that there had been an intention that Veronica be further observed. He identified that failing in his statement?'
Fuller: 'Yes.'
Q: 'But he wasn't invited to a Corrections debrief?'
A: 'I’m unsure who gets invited.'
#JusticeForVeronicaNelson

Counsel for Aunty Donna Nelson: 'Let’s go to the statement [that the same nurse] provided to the Coroners' Court. That concession that he made back on his earlier statement within CCA has been omitted from this statement to the Coroner.'
Fuller: 'Yes.'
#JusticeForVeronicaNelson

Counsel for Aunty Donna Nelson: 'Correct Care Australasia was treating this as a legal problem. They weren’t looking to improve patient care. They were looking to cover up deficiencies in the care provided to Veronica.'
#JusticeForVeronicaNelson

Christine Fuller: 'I don’t believe that that was the intention. If there was an opportunity to make those improvements, we will and we do.' #JusticeForVeronicaNelson

Q: 'Correct Care Australasia held more information than it provided to Justice Health or the Coroners' Court. The inference we will draw from this is that Correct Care was covering up Veronica's treatment.'
A: 'I don’t believe that was the intention.'
#JusticeForVeronicaNelson

Q: 'Important information was omitted as a result. These changes to statements, the failure to provide statements to other reviews. All of these processes had insufficient information.'
A: 'Yes. The review process needs to be reviewed.'
#JusticeForVeronicaNelson

Fuller: 'As I said, we wait for those [external] reviews and this inquest's findings because it's been our experience that we are not to interfere with the Coroner’s inquest. We are happy to take recommendations to change that practice.'
#JusticeForVeronicaNelson

Q: 'Is it genuinely your evidence that undertaking a review of a death in custody would interfere with an inquest? What’s wrong with taking statements early, conducting root cause analysis and providing those statements to the Court?'
A: 'I'm happy to take guidance on that.'

Q: 'Aunty Donna Nelson will likely submit that a deliberate decision was made by CCA to hide a whistleblower's evidence from the Coroner.'
A: 'I don’t believe there is any evidence of that. We didn’t hide any information. We didn’t cover anything up.'
#JusticeForVeronicaNelson

A: 'We made changes to observation and deterioration policies, to instruct staff on known local procedures that weren’t clearly documented.'
Q: 'As result of Veronica’s passing?'
A: 'In relation to the passing of Veronica.'
Q: 'You do see that this sounds like a review.'

Q: 'When you want to make changes, how do you do it?'
Fuller: 'We have a meeting that brings together all of Correct Care Australasia's senior clinical team.'
Q: 'Was Veronica’s passing mentioned in one of these meetings?'
A: 'No, not directly.'
#JusticeForVeronicaNelson

Aunty Donna Nelson's counsel: 'I want to suggest that the failure of CCA to conduct a review after the passing of Veronica, shows a total lack of concern for the health of prisoners like Veronica. It imperils their safety. Do you agree?'
A: 'No.'
#JusticeForVeronicaNelson

Counsel for Aunty Donna puts a final question to Christine Fuller. 'If you are still unable to acknowledge the total failure of Correct Care Australasia, I want to suggest to you that CCA cannot be trusted to safely provide medical care.'
Coroner: 'Do you agree?'
Fuller: 'No.'

Fuller is now being examined by counsel for Doctor Brown (CCA).
Q: 'In your involvement with this sad death, are you able to shed any light on why [a nurse] did not undertake those observations [Dr Brown] asked for?
A: 'My understanding is that he didn’t recall being asked.'

Counsel for the Law and Advocacy Centre for Women is now putting questions to Fuller.
Q: 'What do you understand are your obligations under the Human Rights Charter?'
A: 'To maintain every person's human rights, even though they are in custody.'
#JusticeForVeronicaNelson

Q: 'Have you had training on the Charter?'
A: 'I have not, but I have read the Charter. CCA has a human rights policy and I have tried to give practical examples of human rights in a correctional setting.'
#JusticeForVeronicaNelson

Q: 'I take it then that Correct Care Australasia staff don't have specific training under the Charter?'
A: 'They don’t have specific training, but are made aware of the policy and the dimensions of care that provide access to human rights.'
#JusticeForVeronicaNelson

Q: 'Do you agree that those who don’t learn from history are doomed to repeat it?'
A: 'Yes.'
Q: 'And that that's the value of having a robust human rights framework and educating your employees?'
A: 'Yes.'
#JusticeForVeronicaNelson

Counsel for Correct Care Australasia will now put questions to Christine Fuller (CCA's Deputy CEO).
Q: 'You do consider issues that a death raises, and make improvements where needed?'
Fuller: 'Yes.'
#JusticeForVeronicaNelson

Q: 'You have actively participated in this inquest. Have you found it's a useful process, from your perspective?'
A: 'Yes.'
Q: 'Compared to Justice Heath review?'
A: 'It's much more useful in that you see a lot of information. You understand what’s being done by other parties.'

Q: 'It has provided an opportunity for you to reflect on the care that Veronica was provided?'
A: 'Yes.'
Q: 'And on what you might do going forward?'
A: 'Absolutely.'
#JusticeForVeronicaNelson

Counsel for Correct Care Australasia: 'Concerning the relationship with Justice Health, it's very important that it's clear. Pursuant to contractual arrangement, Justice Health monitors whether CCA is meeting performance indicators like KPIs?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'If Justice Health perceives that you have failed in your contractual duties, you can receive penalties?'
Fuller: 'Yes.'
Q: 'There are quarterly audits?'
A: 'There are clinical performance audits and reports and action plans come from those.'
#JusticeForVeronicaNelson

Q: 'Would you describe the relationship between Correct Care Australasia and Justice Health as a collaborative one?'
A: 'Yes.'
#JusticeForVeronicaNelson

Fuller is asked about Aboriginal patient experiences. She lists yarning circles, guidance by Elders, attempting to secure funding to get an Aboriginal health officer at DPFC, consulting with ACCOs, trying to train Aboriginal nurses, culturally- and trauma-informed counselling.

Counsel for Correct Care Australasia: 'Did you on, your last Justice Health review, obtain full accreditation?'
Fuller: 'Our last audit saw us fully accredited with no recommendations for improvement.'
#JusticeForVeronicaNelson

Counsel for Correct Care Australasia: 'If custodial staff elect to place a prisoner in a holding cell, they are responsible to the prisoner, logging this in a custodial log book and performing any observations?'
A: 'Yes.'
#JusticeForVeronicaNelson

Q: 'There was earlier evidence from Governor Jones about difficulties in the relationship between Corrections and CCA over a couple of years?
A: 'Yes, but we have a very close relationship with custodial staff and we value and rely on that. It’s important to maintain.'

Q: 'How do you say it’s tracking presently?'
A: 'We have made a number of changes to leadership team at DPFC, provided extra resources, held joint activities onsite. There's been a number of improvements and they'll continue.'
#JusticeForVeronicaNelson

Counsel for Correct Care Australasia asks about cultural competency.
A: 'We’ve always provided cultural awareness training to all of our staff. We also offer a range of in-service and others through ACCOs. We’ve partnered with Blue Knot around trauma-informed care.'

Q: 'You’ve requested funding from Justice Health for an Aboriginal Health Worker?'
A: 'Yes, we don’t have one at Dame Phyllis Frost Centre and we think it's important role.'
#JusticeForVeronicaNelson

Counsel Assisting now poses the final questions for this inquest to Christine Fuller.
Q: 'Are you able to provide us with the precise number of prisons that CCA provides primary health services for?'
A: '15 public adult prisons, and two youth justice centres. Only in Victoria.'

Counsel Assisting clarifies the number of women who have died in Dame Phyllis Frost since Veronica passed: four.
Q: 'Does that match your memory?'
A: 'I couldn’t tell you off the top of my head. I don’t know where you got the information.'
Q: 'I got it from the Coroners Court.'

The final hearing of the inquest is now drawing to a close. Counsel Assisting tenders the coronial brief and additional materials.
Christine Fuller: 'I would like to offer my condolences to Veronica’s partner, family, friends and community. I am very sorry for your loss.'

Aunty Donna Nelson (Veronica's mother) and Uncle Percy Lovett (Veronica's partner) present a joint statement of thanks to community and supporters through their counsel. We will share that statement with you in full as soon as we can. #JusticeForVeronicaNelson

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