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Jan 29 148 tweets 44 min read
Good morning from Boon Wurrung Country. At 10:30am Coroner Simon McGregor will hand down the findings from the coronial inquest into the death in custody of Veronica Nelson. Shortly, there will be a smoking ceremony outside of the coroner’s court. #JusticeForVeronicaNelson
If you are in Melbourne please come down to the court to show your support for Veronica’s family. If you can’t make it down, we will be live tweeting or alternatively you can watch the livestream here.

ccovwebcast.com.au/finding-into-t…

#JusticeForVeronicaNelson
This morning Veronica's loved ones gathered outside of the coroner's court. Veronica was a Gunditjmara, Dja Dja Wurrung, Wiradjuri & Yorta Yorta woman. She belonged to a large family, with 6 siblings & 10 children that she loved & cared for as her own #JusticeForVeronicaNelson
Coroner McGregor begins: Veronica was loved and respected by those that knew her, yet Veronica died while alone in the Dame Phyllis Frost Center. She passed away after begging for assistance for several of the last hours of her life

#JusticeForVeronicaNelson
Coroner cont: [Veronica] was found the next morning on the floor of a cell in a prison built on the lands of the Wurundjeri & Boon Wurrung people. That Veronica was separated from her family, community, culture & country at the time of her passing is a devastating & demoralising
For those attending the court this morning in support, Court room 3 has just been opened.

#JusticeForVeronicaNelson
Coroner McGregor: The conditions under which Veronica lived out her final days are harrowing. During the inquest, CCTV footage showed her struggling to walk around her cell, with severe cramping in her legs and feet. #JusticeForVeronicaNelson
Coroner: Footage also showed Veronica projectile vomiting multiple times onto the floor & into her blankets. She was left to lie in her own vomit..In her approx 36 hours time at DPFC Veronica used the intercom 49 times to request assistance... #JusticeForVeronicaNelson
Coroner: The sounds of Veronica’s pleading calls for help echoed around the courtroom...prompting me to ponder how the people who heard them & had the power to help her did not rush to her aid, send her to hospital or simply open the door for cell to check on her
Coroner McGregor: A person in custody is not only deprived of their liberty, but deprived of the ability and resources to care for themselves. In short, the state's control over the person is nearly complete.

#JusticeForVeronicaNelson
Coroner McGregor: When the passing of an Aboriginal person occurs in custody, it occurs on the continuum of the problematic relationship between the Australian criminal justice system and First Nations people.

#JusticeFroVeronicaNelson
Coroner McGregor: The RCADIC...investigated the causes of deaths of 99 Aboriginal people held in the custody of police, prison and juvenile detention centers in Australia in each Australian state and territory.

#JusticeForVeronicaNelson
Coroner McGregor: The Royal Commission also authoritatively links Aboriginal over representation in custody to the continuing consequences of the colonisation of Australia and it's Indigenous people.

#JusticeForVeronicaNelson
Coroner: The significance of access to bail in the over representation of Aboriginal people in custody was also identified by RCIADIC & has continued to feature more reformed reviews conducted by federal the Victorian government...
The Coroner refers to the statutory amendments to bail Act, enacted in 2017 & 2018…noting that these amendments “make it more difficult for all people to access bail with Aboriginal & Torres Strait Islander people, particularly women being disproportionately affected”
Mr Lovett provided the following insights. I've seen Veronica speaking to some white people & people in authority... She was quiet. She doesn't get cheeky. She doesn't get smart. She basically does what they asked her to do. She was always well mannered. #JusticeforVeronicaNelson
Coroner McGregor: As will become apparent, despite the measures in place...intended to ensure Veronica could access culturally relevant support, her journey through the criminal justice system occurred without her speaking to a single Aboriginal person employed in these roles.
On 30/12/19, Veronica was arrested on outstanding warrants by Sergeant Brendan Payne....on Spencer Street in Melbourne. Handcuffing an offender is the use of force and any decision to use force must be made consistent with applicable policy....

#JusticeForVeronicaNelson
While under arrest...I'm satisfied that the use of handcuffs [on Veronica] was not reasonably necessary in most circumstances & an unjustified & disproportionate restriction of the charter of human rights

#JusticeforVeronicaNelson
Coroner McGregor: I found that the use of handcuffs by Victoria Police was unjustified and disproportionate in these circumstances.

#JusticeForVeronciaNelson
Coroner finding on bail: Police...ought to properly consider the discretion to grant bail when it is available… I find that police bail decision maker was empowered to grant Veronica bail & failed to give proper consideration to the profession to do so. #JusticeforVeronicaNelson
Sgnt Payne said that he treated all offenders with respect & the same regardless of Aboriginality…his comment about treating all offenders alike...fails to appreciate the different treatment may be required to ensure that some people enjoy the equal protection of the law
Coroner: I find that the training provided by Victoria Police [in relation to aboriginality and bail and remand] fails to equip its members an adequate appreciation of the vulnerability of an Aboriginal person in custody.

#JusticeForVeronicaNelson
Coroner: There appear to be significant benefit in remand summaries that are disclosed at the outset that an accused person is Aboriginal...I find that Victoria police failed to inform the Melbourne Magistrates Court operators Aboriginality

#JusticeForVeronicaNelson
Coroner: I find the legal assistance provided to Veronica by the VLA junior lawyer service on the 30th and 31st of December 2019, and particularly by Peter Schumpeter, was reasonable and appropriate in the circumstances.

#JusticeForVeronicaNelson
Coroner: I find that the legal assistance provided to Veronica by Law and Advocacy Centre for Women, particularly by solicitor Julian Prior, was reasonable and appropriate in the circumstances.
Coroner: Insofar as the prosecutor did not alert the bail decision maker to the relevance of Veronica's aboriginality During the bail hearing on 31 December, I find that he failed to properly consider Veronica's Charter rights.

#JusticeForVeronicaNelson
Coroner: If Veronica had been legally represented in her application for bail…multiple other matters might have been raised… Mr. Lovett might have been called to give evidence.

#JusticeforVeronicaNelson
Coroner: I find that given Veronica's legal representative of record had been notified to be Legal Aid....Veronica should not have appeared unrepresented on [31 Dec 2019]

#JusticeforVeronicaNelson
Coroner: In the criminal justice system, therapeutic interventions are often coerced with non compliance having the potential to contravene court orders and attract further criminal penalties.

#JusticeForVeronicaNelson
Coroner: In short, drug dependence is not universally regarded as a condition and the correctional system becomes a proxy for appropriate social service supports in the community.

#JusticeforVeronicaNelson
Coroner: There is a clear link between our lack of available support or treatment for drug dependency and the remand of an accused individual with drug dependence.

#JusticeForVeronicaNelson
Coroner: Substance Use Disorder is often used by the prosecution to allege that an accused presents an unacceptable risk of bail & should be refused bail...There remains a severe service gap with wait periods for the services that are available, extending to 4/5 months.
Coroner: Despite the Magistrates Courts commitment to maximizing the availability of supports for Koori people...the only measure in place to ameliorate Veronica's experience...failed her.

#JusticeForVeronicaNelson
Coroner: I find that culturally specific support for Aboriginal court users at the Melbourne Magistrates Court was under resourced on 30 and 31 December

#JusticeForVeronicaNelson
Coroner’s Findings in relation to 2018 Bail Act

Coroner: Before the 2018 bail Act changes, only a small number of very serious offenses attracted the highest reverse onus threshold for the granted bail. This is no longer the case.

#JusticeForVeronicaNelson
Coroner: Even if an accused person satisfies the valid decision maker that reverse onus threshold for bail is met, Victoria Police are likely to allege that they would pose if failed, and unacceptable risk of one of the four types specified in the act.

#JusticeForVeronicaNelson
Coroner: Rather than being confined to risk to safety… the unacceptable risk in these needs have become an equation with risk with the discriminatory effect…

1/3

#JusticeForVeronicaNelson
Coroner cont: If an accused is homeless, suffering from mental illness & drug & alcohol dependence, they will present to the court as an increased risk of failing to appear, & of committing further offences. They are more likely to be refused bail

2/3

#JusticeforVeronicaNelson
Coroner cont: The sections of the community disproportionately affected by social disadvantage, are unsurprisingly disproportionately affected by these provisions of the bail act.

3/3

#JusticeforVeronicaNelson
Coroner: I find the Bail Act has a discriminatory impact on First Nations people, resulting in grossly disproportionate rates remanded in custody, the most egregious of which affects alleged offenders who are Aboriginal and Torres Strait Islander women

#JusticeForVeronicaNelson
Coroner McGregor: The wide reach of the reverse onus test has caused accused to flood into the criminal justice system.

#JusticeForVeronicaNelson
Coroner: The complete & unmitigated disaster of the 2018 changes to the Bail Act is most obviously inflicted on the accused who are incarcerated, often for short periods & for unproven offending of a type that often ought not result in imprisonment even if proven...
Coroner: Short periods in custody are destabilizing & often serve to exacerbate issues underlying the person's alleged offending by producing a loss of housing, work or income, the breakdown of relationships and support networks & disrupted access to treatment and other services
Coroner: The [reverese onus] provisions incentivise a plea of guilty to avoid time in custody where the prospects of bail are limited.

#JusticeforVeronicaNelson
Coroner: The current rate of remand might be contributing to the recidivism rate…,personal and socio economic consequences having a criminal record conviction or serving a term of imprisonment are broad ranging and long lasting and are likely to entrench social disadvantage.
Coroner McGregor: The administration of justice conclave unanimously recommended to me that the bail act be amended urgently. I endorsed the proposals to reform the Bail Act.

#JusticeforVeronicaNelson
Since the Bourke Street tragedy, there was an unwritten Vicpol internal policy re: grating bail which in effect meant decision makers are less likely to grant Bail. The Coroner agreed a decision had already been made during the police interview to remand Veronica
Coroner's findings in relation to Veronica's reception interview & medical assessment at DPFC

Coroner: The Vic Prison Opioid Substitution Therapy Program Guidelines dictate that a 6 week stabilization period is required before a person in custody is eligible for pharmacotherapy
Coroner: Veronica was prescribed a standard withdrawal pack…it was effectively a one size fits all package… regardless of the prisoner’s level of opioid dependence or the severity of the withdrawal symptoms…

#JusticeforVeronicaNelson
Coroner: If Veronica was in the community, she would have had a range of opioid replacement therapies available to her. She would have been able to avoid the painful process of withdrawal together.

#JusticeForVeronicaNelson
Coroner: Indeed, having regard to Veronica's physical condition, the medical conclave...would have discouraged withdrawal if she was in the community...[The treatment Veronica received] was described [by the Medical Conclave] unanimously as inhumane.

#JusticeForVeronicaNelson
Coroner: I find Justice Health's guidelines inadequate insofar as they restrict access to pharmacotherapy to deny prisoners equivalent care that is available in the community.

#JusticeforVeronicaNelson
Coroner: I also find that the [Justice Health] guidelines infringe prisoners’ rights to be treated humanely when deprived of liberty & their right to life given the greater risk of a fatal overdose.

#JusticeForVeronicaNelson
Coroner: I find that because of the opioid substitution program, Veronica did not have access to health services equivalent to those available to her in the community

#JusticeForVeronicaNelson
Coroner's findings in relation to the med assessment conducted by Dr Runacres

Coroner: In response to the error recording that Veronica was not withdrawing from alcohol/drugs, Runacres said he didn't changed the pre-populated entry as he didn't believe anyone would look at it
Coroner: Ms Hills gave evidence that during the reception medical assessment, Veronica was not well & was unable to walk to the scales. Dr. Runacres denied these assertions. He maintained that Veronica was not unwell. He called Nurse Hills a liar.
#JusticeForVeronicaNelson
Coroner: I also note that Dr. Runacres was the only Dame Phyllis Frost staff member on 31st of December, who maintained that Veronica was not unwell.

#JusticeForVeronicaNelson
Coroner: I found Dr. Runacres inability to provide any evidence of independent recollections to be extremely convenient, given the competing accounts of other staff members and the objective evidence indicating Veronica was very unwell

#JusticeForVeronicaNelson
Coroner McGregor: Dr. Runacres evidence was not corroborated and at times, self serving and implausible

#JusticeForVeronicaNelson
Coroner McGregor: On the weight of available evidence, I am satisfied that Dr. Runacres was an unreliable witness. To the extent there is inconsistency, I prefer the evidence of Nurse Hills.

#JusticeForVeronicaNelson
Coroner McGregor: Later...I'll expand upon the impact that drug use stigma had on the quality of care Veronica received...however I highlight the problematic distinction made by Dr. Runacres between someone who he would consider sick & someone who...is in a state of withdrawal.
Coroner: Supervisor Annika... said that Veronica had one of the worst cases of withdrawal she had ever seen. Very, very underweight, very lethargic. Stooped over in what looked like stomach aches...Everybody could see Veronica was so unwell.

#JusticeForVeronicaNelson
Coroner: It is of note that lay people who regularly work in custodial settings seemingly considered that Veronica's health was of particular concern, compared to other new receptions

#JusticeForVeronicaNelson
Coroner: In view of the combined weight of this evidence & the available CCTV footage, I'm satisfied that Veronica was very unwell at the time of her reception medical assessment.

#JusticeForVeronicaNelson
Coroner: I find that Veronica weighed around 33kg at the time of her reception medical assessment, and that the weight recorded by Dr Sean Runacres on the medical reception intake form is inaccurate.

#JusticeForVeronicaNelson
Coroner: I find that physical examination of Veronica was not conducted on 31 December 2019, although three examinations were recorded as having been undertaken in the form of the initial appointment notes by Dr Sean Runacres

#JusticeForVeronicaNelson
Coroner McGregor: I find that Veronica was unwell at the time of her reception medical assessment, and her presentation warranted transfer to hospital.

#JusticeForVeronicaNelson
Coroner: I find that Dr Runacres med assessment & treatment of Veronica on the 31 Dec was inadequate. Runacres failure to physically examine Veronica & to maintain accurate records are significant departures from reasonable standards of care & diligence

#JusticeForVeronicaNelson
Coroner: I find Veronica should have been transferred to hospital at the time of her reception at DPFC & that corrections & care staff continually failed to transfer her to hospital thereafter & this ongoing failure causally contributed to her death

#JusticeForVeronicaNelson
Coroner: On 1 Jan, Veronica projectile vomited into the air whilst lying on her back. The vomit landed on her pillow blankets & on the floor of the cell. She used the income to alert staff & was told there would be people in to clean it up in the morning #JusticeForVeronicaNelson
Coroner McGregor: At the time she was moved, Veronica had been lying in a vomit ridden cell for over 15 hours.

#JusticeForVeronicaNelson
Coroner McGregor's findings on the med handover to Dr Brown.

The handover... was brief and to the effect that Veronica was held overnight in the medical centre... She was told that the patient had been vomiting but was provided no details & so was unaware of the number of times
Coroner: Dr Brown was also not told that Veronica had reported cramping, or how many times she requested and drink overnight, nor that she requested to see a doctor.

#JusticeForVeronicaNelson
Coroner: Neither Dr. Brown or Nurse Hills were aware that Veronica had vomited after their assessment. There was no system in place in the medical centre to record a patient's vomiting or diarrhoea.

#JusticeForVeronicaNelson
Coroner: Three interface points are of special significance to the investigation into Veronica's passing: information exchange, prisoner transfer and treatment at the medical centre itself.

#JusticeForVeronicaNelson
Coroner: It's useful to consider how these 3 interface points functioned in practice, given the depth of policy or procedures governing the systems in place that time fills to manage the healthcare of prisoners at the time of Veronica's reception, were significantly flawed.
Coroner: The inquest identified substantial gaps in policies and procedures which are supposed to safeguard the health and wellbeing of prisoners… women seemingly cannot be adequately cared for in a medical centre overnight

#JusticeForVeronicaNelson
Coroner McGregor: I am deeply concerned that these risks were not identified or addressed by the Department prior to Veronica’s passing.

#JusticeForVeronicaNelson
Coroner McGregor: These risks should have been identified and reported by Correct Care to Justice Health long before Veornica’s passing, as was required by its contractual arrangements.

#JusticeForVeronicaNelson
Coroner: The failure of Corrections & Correct Care to establish adequate procedures & systems for information sharing between staff, mean that overnight on the 31st of December, Nurse George was apparently never notified of Veronica's multiple intercom complaints or vomiting.
Coroner: I'm satisfied that the absence of proper systems of information sharing between Correct Care & correction staff at DPFC, as well as the poor working relationships between staff, prevented critical information from being shared in relation to Veronica’s welfare and care
Coroner: These systemic issues caused major deficiencies in Veronica's care and custodial management, and causally contributed to Veronica's passing.

#JusticeForVeronicaNelson
Coroner: I find that the failure of Correct Care & Corrections to establish proper procedures for information sharing between staff causally contributed to Veronica's passing...

#JusticeForVeronicaNelson
Coroner: The failure of Correct Care & Corrections to establish proper procedures for info sharing meant that decisions in relation to Veronica's medical care and custodial management were made on the basis of incomplete and inaccurate information

#JusticeForVeronicaNelson
Coroner McGregor: I find that the failure of Correct Care and the Department to clearly define the role and purpose of the Medical Center at Dame Phillips causally contributed to Veronica's passing.

#JusticeForVeronicaNelson
Coroner McGregor: I find the Correct Care failed to provide Veronica with care equivalent to the care she would have received in the community, and that contributed to her passing

#JusticeForVeronicaNelson
Coroner McGregor: I also find that Justice Health failed to ensure that Correct Care delivered a standard of health care available in a public health system was obtained through us in the community & this failing causally contributed to her passing

#JusticeForVeronicaNelson
Coroner McGregor: I find that the absence of bed base care to prisoners as the time infringed Veronica's right to life and equality pursuant to sections 8 & 9 of the Charter

#JusticeForVeronicaNelson
Coroner McGregor: The lack of bed based care at DPFC infringes the rights of women prisoners to enjoy human rights without discrimination.

#JusticeForVeronicaNelson
Coroner McGregor: I find that the absence of bed based care at DPFC infringed Veronica's rights to life and equality pursuant to Section 89 of the Charter

#JusticeForVeronicaNelson
Coroner McGregor: I'm satisfied that the failings of both staff to take seriously their obligations in relation to Veronica's care was linked to an assumption that suffering & unwellness was normal for a patient experiencing withdrawal

#JusticeForVeronicaNelson
Coroner McGregor: As a result of this normalization, Corrections & Correct Care staff were not responsive to the obvious signs of Veronica's clinical deterioration & thereby continually fails to recognise that she was in need of urgent medical care.

#JusticeForVeronicaNelson
Coroner McGregor: I'm satisfied that this is evidence of pervasive stigma or dangers towards women who use injectable drugs.

#JusticeForVeronicaNelson
Coroner McGregor: Aunty Vickie Roach spoke of the way in which corrections officers routinely treat drug addicts as a moral issue. She said there's an underlying ideology through corrections that we need to suffer to be corrected.

#JusticeForVeronicaNelson
Coroner McGregor: I find the care & treatment by corrections and Correct Care staff whilst [Veronica was] at DPFC was influenced by drug use stigma, and that this causally contributed to Veronica’s passing.

#JusticeForVeronicaNelson
Coroner McGregor: I find that the treatment of Veronica by correction staff in the morning of 1 January 2020 amounted to cruel & inhumane treatment contrary to Section 10 of the Charter

#JusticeForVeronicaNelson
Coroner: I'm satisfied that Nurse George should have informed herself with Veronica's health status and treatment needs on the night of 31 Dec…I consider the failure to do so was not in keeping with the standards of care one would reasonably expect from a health professional
Coroner McGregor: I am satisfied that this was a fundamental systemic failing & a missed opportunity for Veronica's clinical deterioration to be recorded, assessed, treated and escalated.

#JusticeForVeronicaNelson
Coroner McGregor: I'm satisfied that Veronica should have been transferred to hospital at the time of her reception at Dame Phyllis

#JusticeForVeronicaNelson
Coroner McGregor: I find that the medical records maintained by Correct Care staff were incomplete & contained inaccurate & misleading information about Veronica’s medical history and clinical presentation at Dame Phyllis.

#JusticeForVeronicaNelson
Coroner McGregor: I find that Correct Care's failure to develop an adequate system for the handover of critical information between staff in relation to prisoners at Dame Phyllis causally contributed to Veronica's passing.

#JusticeForVeronicaNelson
Coroner McGregor's findings relating to Veronica's treatment in the Yarra Unit.

Coroner: I find that at the time of her passing, Veronica was in the legal custody of the secretary to the Department of Justice, and community safety.

#JusticeForVeronicaNelson
Coroner McGregor: I am satisfied that the poor standard of care and treatment provided by Nurse George to Veronica between 31 December into January was influenced by drug use stigma

#JusticeForVeronicaNelson
Coroner McGregor: I find that Correct Care staff continually and collectively failed to facilitate Veronica receiving equivalent care and failed to protect her welfare.

#JusticeForVeronicaNelson
Coroner McGregor: I find that Officer Brown failed to escalate Veronica's care on at least three occasions on the morning of 2nd January between 1:30am and 4am.

#JusticeForVeronicaNelson
Coroner: I find Officer Brown failed to physically check on Veronica at any point overnight, particularly after Veronica became unresponsive during the final intercom call around 4am 7 this was a failure to provide appropriate care for Veronica

#JusticeForVeronicaNelson
Coroner McGregor: I find as above that the failure to provide the care and treatment by corrections and Correct Care staff overnight in the Yarra Unit was influenced by drug use stigma & that this causally contributed to Veronica’s passing.

#JusticeForVeronicaNelson
Coroner McGregor: I'm also satisfied and find that Veronica should have been transferred to hospital from the time of her reception of time through onwards, and that staff continually failed to do so.

#JusticeForVeronicaNelson
Coroner McGregor: I find that Nurse George's conduct in relation to Veronica between 31 De into January was lazy, unprofessional & not in keeping with the standards of care one would reasonably expect from a healthcare professional while on shift

#JusticeForVeronicaNelson
Coroner McGregor: The inquest into Veronica's passing identified multiple concerning failings on the part of Corrections, JARO review, Justice Health Dept & Correct Care in relation to the conduct of these inquiries, which I shall now expand upon

#JusticeForVeronciaNelson
The formal debrief in response to Veronica's passing was held in boardroom at DPFC on the 16th of January.

Coroner McGregor: The minutes reveal that 34 Corrections, Correct Care, JARO, Justice Health staff members were invited to the formal debrief. No apologies were noted.
Coroner McGregor: Only six attendees had any interactions with Veronica prior to her passing & Supervisor Reed was the only attendee present who had face to face interaction with Veronica, while she was at DFPC.

#JusticeForVeronicaNelson
Coroner McGregor: The minutes indicate the debrief went without an acknowledgement of Country, and without any recognition of Veronica's Aboriginality, or her identity as a proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman.

#JusticeForVeronicaNelson
Coroner McGregor: I find that the debrief conducted following Veronica's passing did not critically examine the incident, and that the minutes of the debrief were grossly inadequate and misleading.

#JusticeForVeronicaNelson
Coroner: The death in custody report contains much erroneous info…[including] that on 2 Jan Nurse George was busy caring for a number of prisoners in the Med Center. We know this was not the case as CCTV footage showed she sat in the nurse's station all night, watching a movie
Coroner: The Deaths in Custody Report lacked relevant information, including any mention of Veronica being kept in the Medical Centre overnight because she was unwell or the fact that Veronica had requested methadone multiple times

#JusticeForVeronicaNelson
Coroner: [Absent in The Deaths in Custody Report was] the number of times Veronica requested assistance and reported symptoms overnight in the medical centre the number of times Veronica vomited in the medical centre

#JusticeForVeronicaNelson
Coroner: [The Deaths in Custody Report was absent] the fact that Veronica had to move multiple times between cells in the medical centre due to vomiting. The number of times Veronica had used the intercom overnight on the unit to request assistance.

#JusticeForVeronicaNelson
Coroner McGregor: I find that the Justice Health Deaths In Custody report regarding Veronica's passing was grossly inadequate and misleading.

#JusticeForVeronicaNelson
Coroner McGregor: I find that the JARO Review of Veronica’s passing was grossly inadequate and misleading

#JusticeForVeronicaNelson
Coroner: I consider these to be an appalling lack of disclosure by Correct Care...under the Charter of Human Rights in this state. I find that Correct Care failed to provide critical information to Justice Health at the time of Veronica's passing.

#JusticeForVeronicaNelson
Coroner McGregor: I find that correct care’s failure to undertake a root cause analysis in the internal review at the time of Veronica’s passing was contrary to the requirements of the Justice Health Quality Framework.

#JusticeForVeronicaNelson
Coroner: Correct Care also failed to inform Justice Heath that a staff member had been tasked with collecting statements in relation to Veronica's passing and treatment...I consider these to be an appalling lack of disclosure by Correct Care...under the Charter of Human Rights
Coroner McGregor's key recommendations included:

Referring the case to the Director of Public Prosecutions, specifically noting his findings in relatino to Doctor Sean Runacres and Nurse Athena George.

#JusticeForVeronicaNelson
Coroner McGregor: I am satisfied there is evidence of a sufficient level more than a mere suspicion or conjecture for me to find the belief that an indictable offence might have been committed

#JusticeForVeronicaNelson
Coroner McGregor: I recommend the Vic Gov in consultation with VicPol, Dep Justice, the Dep of Health and peak Aboriginal orgs develop a review & implementation strategy for the state's implementation of the 339 recommendations from the RCIADIC.

#JusticeForVeronicaNelson
Coroner McGregor: I recommend the urgent review of the Bail Act with a view to repeal any provision that has a disproportionate adverse effect on Aboriginal or Torres Strait Islander people.

#JusticeForVeronicaNelson
Coroner McGregor: I find that had the Royal Commission recommendations been successfully implemented by the government and its agencies, Veronica's passing would have been prevented.

#JusticeForVeronicaNelson
Coroner McGregor: I am satisfied there were several missed opportunities to intervene to prevent Veronica's passing and if she'd been sent to hospital at any point. I find that Veronica's death was preventable.

#JusticeForVeronicaNelson
Coroner: Had Veronica's passing not proceeded to a coronial inquest, the findings of JARO review, Deaths in Custody report & formal debrief would have remained as the... only official investigations...

It is a deeply concerning prospect to contemplate.
#JusticeForVeronicaNelson
Coroner McGregor: The disturbing Don't Ask Don't Tell arrangement between the Dept and Correct Care appear to have had with one another is a matter of grave public interest

1/3
#JusticeforVeronicaNelson
Coroner McGregor (cont): ...and goes part of the way to explaining how so many continual and repeated systemic failings were permitted to occur in this case. 12 months after Veronica's passing, four more women died...

2/3
#JusticeforVeronicaNelson
Coroner (cont): It is clear that the current approaches are not working and these failures continue to carry a human cost...

What is needed is responsive culturally informed policymaking policy which listens to the cries of First Nation voices...

3/3
#JusticeforVeronicaNelson
Coroner McGregor: Tokenistic policies of inclusion and anti-discrimination are not going to cut through and have not been anywhere near effective enough.

#JusticeforVeronicaNelson
The Coroner made many more detailed recommendations about how to change the system, which we have not detailed here, but will be available on the transcript.

#JusticeforVeronicaNelson
Coroner: I recognise that this inquest largely involved others telling the stories of Veronica's life and passing. Police, judicial officers, prison guards, custodial health workers, and heads of organisations did not know Veronica and did not understand who she truly was.
Coroner McGregor: To remember the person Veronica was and the daughter that Aunty Donna has lost, I allow [Veronica] to close these findings in her own words.

#JusticeForVeronicaNelson
Coroner McGregor: I wish to convey my sincere condolences to Aunty Donna, Percy and Veronica's family, friends and community for their loss. I hope the close of this inquest brings you some small peace…

1/2

#JusticeForVeronicaNelson
Coroner cont: …as you go from here to tell Veronica’s story in your own words and remember her as she would have wanted to be remembered, as a wise, kind, strong and proud Aboriginal woman who saw hope, beauty and goodness in herself and others even through the darkness.

2/2
The Coroner's voice was breaking with emotion whilst reading the conclusion and recommendations. Overwhelmingly, community attending the hearing appeared visibly distressed and many were in tears.

#JusticeForVeronicaNelson
Veronica's family have published a statement

Veronica was my first-born child, & she was my best friend. She was kind, caring & compassionate. She was loved by her family, her community, & her friends. She was a proud Aboriginal woman who loved her culture.

- Aunty Donna Nelson
To the law makers, I want you to sit and listen to Veronica’s final hours. I want her voice to ring in your ears until you realise that our justice system is broken. Veronica should never have been locked up.

- Aunty Donna Nelson, Veronica's mum.
After the hearing ended, Veronica's family gave statements to the press. We encourage you to read and share the articles to platform their voices at this time.

#JusticeforVeronicaNelson
We know that today’s findings have been really distressing. For all Mob reading, please take care and check in on one another.

Please reach out if you need support from the following numbers:

13YARN - Call 13 92 76;

Brother to Brother 1800 435 799;

Lifeline 13 11 14.
Thank you for following today & supporting Veronica Nelson’s family. These are historic, powerful findings & we send all of our love and strength to Veronica’s family at this time.

#JusticeForVeronicaNelson

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More from @dhadjowa

Jan 29
Tomorrow at 10am Coroner Simon McGregor will hand down the findings of the inquest into the death of Gunditjmara, Dja Dja Wurrung, Wiradjuri & Yorta Yorta woman Veronica Nelson. Veronica's family welcome in person community attendance. #JusticeForVeronicaNelson
For those who can't attend in person tomorrow but wish to show their support for Veronica's family, you can listen to the livestream here: ccovwebcast.com.au/finding-into-t…

We will also be live tweeting the findings here. #JusticeForVeronicaNelson
This afternoon, a smoking ceremony in honour of Veronica Nelson will be held at Kaielthban Park, 25 Archer Street, Mooroopna at 3:30pm. Veronica's mum, Aunty Donna Nelson, and the community are coming together before the Coroner’s findings tomorrow.

#JusticeForVeronicaNelson
Read 7 tweets
Nov 1, 2022
On Monday 31 October, the inquest into the death of Kumanjayi Walker sat on Arrernte Country with Superintendent Nobbs continuing his evidence.

Below, we share some key excerpts. You can find the full link to the transcript here: justice.nt.gov.au/__data/assets/…

#JusticeForWalker
Counsel for Brown family: Now, Sergeant Frost was, of course, stressed and fatigued at this stage?

Nobbs: Correct.

Q: Now, at one point, she expressed to you that she was afraid the police station would be set on fire with the police in it. Do you recall that?

A: Yes.
Q: As you pointed out to her at the time and you told police officers in your interview, there was zero evidence or information to suggest that?

A: Zero evidence to suggest that the police station could be set on fire, but again, reasonable apprehension that Sgt Frost had...
Read 27 tweets
Oct 31, 2022
On Friday 28 October, the inquest into the death of Kumanjayi Walker sat on Arrernte Country with Claudia Campagnaro giving evidence.

Below, we share some key excerpts. You can find the full transcript here: justice.nt.gov.au/__data/assets/…

#JusticeForWalker
Counsel Assisting: Ms Campagnaro, can you see and hear me okay?

Campagnaro: Yes.

Q: Could you please state your full name for the court?

A: Claudia Campagnaro

#JusticeForWalker
Counsel Assisting: You were asked by police in the Northern Territory to participate in that interview because of a previous relationship that you had had with Constable Zachary Rolfe, is that right?

Campagnaro: That's correct.

#JusticeForWalker
Read 61 tweets
Oct 31, 2022
On Thursday 27 October, the inquest into the death of Kumanjayi Walker sat on Arrernte Country with Sergeant Meacham King's evidence continued. Below, we share some key excerpts.

You can find the full transcript here: justice.nt.gov.au/__data/assets/…

#Justice4Walker
Sgt King is cross-examined by Mr Edwardson.

E: [Y]ou would have required a community police officer to be in your presence or to accompany you ideally when you went in the community that night?

MK: If we were out there looking to arrest someone, yes...

#Justice4Walker
Regarding the chain of command for the plans made on the day.

E: [U]ltimately the chain of command goes from then to Sergeant Frost who in turn goes up in this case to Superintendent Nobbs who in turn goes up to Assistant Commissioner Wurst?

MK: Yeah, I’d agree with that.
Read 85 tweets
Sep 6, 2022
Good afternoon, today is the second day of the coronial inquest into the death of Kumanjayi Walker which is taking place on Arrernte Country, Mparntwe. Please join the family in solidarity by listening in via the live stream: justice.nt.gov.au/attorney-gener…
The first person to take the stand is Peggy Dwyer who is counsel assisting the coroner. She begins with some contextual comments about the poor conditions within prisons in the Northern Territory and the Don Dale Royal Commission.
Dwyer tells the court that the lack of appropriate services and poor conditions within youth detention centres contributes to the potential for harm of children and young people who already suffer from trauma. #Justice4Walker
Read 39 tweets
Sep 5, 2022
Greetings from Arrernte Country. Today is the first day of the coronial inquest into the death of Kumanjayi Walker. The inquest is being live-streamed so you can listen in here: justice.nt.gov.au/attorney-gener…
This is the first inquest we are aware of that is being translated in Warlpiri and using interpreter services. As the event is being live-streamed, today we will be tweeting highlights only. #JusticeForWalker
Coroner Libby Armitage takes the stand and opens by giving an Acknowledgement of Country and making some opening comments. This coronial inquest is being live-streamed and translated into Warlpiri. #JusticeForWalker
Read 30 tweets

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