The 37-year-old died in a cell at the Dame Phyllis Frost Centre early on January 2, 2020, from an undiagnosed medical condition after screaming in pain and calling for help nine times.
Aunty Donna Nelson, who lives in the Shepparton area, requested her daughter be referred to as Veronica during the inquest, which is expected to last five weeks and hear from more than 60 witnesses.
“This inquest is first and foremost about Veronica, and how a broken criminal justice system locked my daughter up and let her die while she begged for help, over and over,’’ she said.
The inquest heard evidence during the first week that Veronica was remanded in custody after representing herself in a bail application.
She was arrested in Melbourne on a warrant for failing to appear at court in Shepparton on shop stealing charges.
The magistrate who issued the warrant noted she could be released to appear in court at Shepparton.
Lawyer Peter Schumpeter was allocated Veronica’s case when she was due to appear in Melbourne Magistrate’s Court after her arrest in December 2019.
Veronica was required to show exceptional circumstances to justify a bail application, because she was charged with breaching bail.
Mr Schumpeter told the inquest that, working at the “coalface”, he believed a number of people being brought before Melbourne’s Bail and Remand Court should not be there.
“I understand the rationale for introducing tougher bail laws — I don't agree with it, but I understand the rationale,” he said.
“But the consequences weren’t properly foreseen.”
He believed Veronica’s case for bail had merit and tried to arrange it so she could be assessed for a community bail program the following day.
For the year before her death, Veronica had used Jill Prior, from the Law and Advocacy Centre for Women, as her lawyer.
Ms Prior was on leave and a referral was made to another lawyer.
Tass Antos, who was given a brief to represent Veronica, said he believed there were “high hurdles” for bail.
He couldn’t recall details of meeting Veronica but in an email to Ms Prior he called Veronica “aggressive and dismissive” and said her bail had “unsurprisingly” been denied.
Mr Antos brought up the possibility of him suggesting Veronica apply for bail herself, so as to preserve her right to have a represented bail application later.
In her evidence, Ms Prior said it was unlikely Veronica would have served any time in prison if she was convicted of charges she was accused of.
The inquest is examining the adequacy of prison healthcare and the impact of Veronica’s Aboriginality on her death, as well as Victorian bail laws.
She died from complications of Wilkie’s syndrome, in a setting of withdrawal from chronic opiate use.
The rare syndrome is characterised by nausea and vomiting, which can lead to fatal electrolyte imbalances.
“(Veronica) may have passed of natural causes but if it could have been avoided, it should have been,’’ counsel assisting the coroner Sharon Lacy said.
“If her pain could have been alleviated, it should have been.
“She was detained and in state care. She was entitled to be treated with dignity, in life and in passing.”
— with AAP