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A Professor with more than two decades of experience in prison healthcare has told an inquest that it would be hard to "discount" racism as a factor in the death of an Aboriginal woman in custody.
Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman, Veronica Marie Nelson, was found dead on her cell floor at the Dame Phyllis Frost Centre in January 2020.
An autopsy listed Nelson's cause of death as complications of Wilke's syndrome "in the setting of withdrawal from chronic opiate use".
An inquest into her death has been examining the adequacy of prison healthcare, the impact of her Aboriginality and Victorian bail laws.
Testimony already heard at the Melbourne Coroner's Court has included: a nurse accusing a doctor of fabricating a health assessment of Ms Nelson upon her arrival at the prison; the same doctor admitting he made errors on her medical files, including failing to declare she was withdrawing from drugs; and that Ms Nelson's was told to 'be quiet' while screaming and pressing her cell's intercom for help.
Wiradjuri woman and Professor at the University of Sydney’s National Centre for Cultural Competence, Megan Williams questioned whether systemic racism within the prison healthcare system had played a part in her death.
“The question does need to be asked about the extent to which this is discriminatory as well,” said Professor Williams.
“We don’t know how often this occurs in that setting and among who and what cultures those people are.
“But we do know that within the community setting, Aboriginal and Torres Strait Islander people frequently experience interpersonal racism.”
Photo of Veronica Nelson with partner Percy Lovett Source: Percy Lovett
Panel acknowledge multiple failures
Ms Williams was one of a panel of experts who had all reviewed evidence presented to the inquest so far as to provide observations.
Counsel Assisting, Sharon Lacy asked the group if Ms Nelson’s death could have been prevented and at what point would it have been too late.
"It was identified at around 11 am on the 1st of January, that there had been a significant change in her clinical condition," said Director of Emergency Medicine at Melbourne's St Vincent Hospital, Dr Andrew Walby.
"The aspects of that were, repeated vomiting, dehydration, the changes in her vital signs and then again two hours later, there was an ongoing vomiting, new cramping in her lower limbs and she'd been committing some brown coloured fluid.
"Our consensus view at that point is that she needed to be transferred to hospital and that would've given the opportunity for her death to be prevented."
Other panel members had differing views, highlighting the costs of medical transfers and the breakdown in communication between handovers from doctors.
Clinician and addiction specialist, Dr Matthew Frei had the view that the conduct of Dr Sean Runacres was "reasonable" when he treated Ms Nelson and refrained from sending her to hospital.
"My thought was, well, most of the other management decisions may not have been adequate," said Dr Frei.
"That decision was not unreasonable, given the information available to him (Dr Runacres).
"I don't know necessarily that my view of dissent was that it wasn't completely inadequate, but in my view, not to send her to a hospital at that point, given the implications of doing that, wasn't unreasonable."
The Dame Phyllis Frost Centre where Ms Nelson died. Source: RMIT.
Breach of human rights
Dr Susan Bell said there was also a consensus among the group that her treatment in the days and hours before her death was inhumane.
“Many of us were deeply concerned that her human rights had been breached,” said Dr Bell.
“The way she died was alone and without dignity and was unnecessary and I think that the system… all of the people involved need to reflect on that.
“It’s not just whether one individual was more at fault than another, medicine and provision of healthcare is a team game.”
However, the panel agreed that the actions and healthcare provided to Ms Nelson by registered nurse Stephanie Hills were appropriate, but said she failed in her duty when she did not override Dr Runacres's call not to send Ms Nelson to the hospital after he had left.
“We agree that the assessment was reasonable, but the management was not reasonable in that, given the discrepancy of the opinion with Dr Runacres, that placed an onus on Ms Hills to escalate the issue in some way,” one medical expert said.
Dr Runacres was accused by Nurse Hills earlier in the inquest of fabricating Ms Nelson’s medical health assessment on her arrival at the Dame Phyllis Frost Centre.
The inquest continues.
