There’s this underlying ideology throughout corrections that we should suffer, that we need to suffer, to be corrected.

Aunty Vicky Roach

Aboriginal woman Veronica Marie Nelson passed away on the floor of a prison cell on 2 January 2020, after days of crying out for help. Three years later, a Coroner found that if she had received the healthcare she needed, she would not have died.

The underlying logic of the carceral system is that certain people must be made to suffer to keep the rest of the community safe. It’s a maddening lie which has been repeated so many times that we’ve forgotten there are other ways to address harm.

While healthcare in prisons is meant to be the same as that provided outside, this is far from the reality. Rather, prison healthcare, or the absence thereof, is an extension of the logic of prisons — its own distinct form of punishment.

I represented Veronica’s partner, Uncle Percy Lovett, in the coronial inquest into her passing, and continue to represent him in fighting for justice for Veronica. I also represent people in prison and other families who have prematurely lost their loved ones to the carceral system.

Uncle Percy has described Veronica to me as deeply spiritual — a proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman. She loved AC/DC, was clever, would speak her mind, and had a big personality and beautiful laugh. She is dearly missed by her family and community, especially her mother, Aunty Donna Nelson, with whom she shared a sister-like bond. In Veronica’s own words, “My mother has always been like my father — someone who knows the song in my heart — and they have always been the ones to sing it back to me when I have forgotten the words.”

In the last three years, I have listened and watched hours of intercom recordings and footage of Veronica’s final days. It haunts me. During the three days she was in prison, Veronica’s painfully polite requests for help were repeatedly ignored or dismissed by prison and medical staff. Veronica pressed the intercom buzzer in her cell, her only lifeline, at least 49 times.

Not only did guards ignore or dismiss her, they prevented healthcare access, gave unqualified healthcare advice, and responded with inhumanity and degradation. Veronica was made to lie in her own vomit for hours. Non-medically-trained guards recommended salt. Veronica was repeatedly told to stop pressing the buzzer — told that it was “for emergencies only”. On her final day alive, after reporting severe cramps, pain and vomiting, she was told that there was nothing much that could be done. In her last hours, she screamed out for help and, while in pain, cried out for her late father. The guard on duty, Tracey Brown, told her to “try to stop” because she was “keeping the other prisoners awake”. The other women in prison with Veronica repeatedly tried to seek help for her while they remained locked in their cells.

Even when medical staff did see Veronica, they ignored clear signs that she needed to go to hospital. The first doctor who saw Veronica, Dr Sean Runacres, was found to have failed to conduct any physical examination of her, to have written inaccurate and misleading notes, and to have dismissed a nurse who said Veronica needed to go to hospital.[1] Other doctors and nurses who saw her continued to overlook her symptoms.

After only two nights in prison, Veronica passed away from malnutrition caused by opioid withdrawal and a gastrointestinal illness. Her death was entirely preventable. She needed to go to hospital from the moment she entered prison. Her life could have been saved by an intravenous drip.

The prison environment, by its very nature, is one which makes people unwell. But people in prison, like Veronica, are not free to access healthcare when they need it. They cannot go to their family or trusted doctor and cannot take themselves to an emergency room. Except in the ACT, First Nations people cannot access Aboriginal community-controlled health services that provide healthcare that meets their social, emotional and cultural needs.

Rather, in their cells, their only lifeline is an intercom that connects to a non-medically-trained prison guard. That guard decides whether to relay critical health information to a nurse. The intercom is a lifeline; this is the point at which the physical space of the prison cell connects to the outside world, the patient to the nurse. By cutting off that connection, and by ignoring calls for help, guards re-enact the punitive logic of the prison, which cuts people off from their communities and any form of care. This is antithetical to health care, which for all cultures and settings is to be timely, non-discriminatory, respectful, safe and collaborative.

An inquest into Veronica’s death was not considered mandatory as it was deemed “natural causes”. When I started acting for Uncle Percy, the story of Veronica’s death, told by the government and private prison health provider Correct Care Australasia, was that, although tragic, it was unavoidable. Statements from critical witnesses were conveniently left out of the inquest brief of evidence until shortly before the inquest, and internal reports stated that “[m]aybe this incident would not have been handled as well at a different prison”. Uncle Percy thought this was a cover-up.

In the end, the Coroner found that the government and Correct Care had engaged in “grossly misleading” conduct after Veronica’s passing, which went “part of the way to explaining how so many continual and repeated systemic failings were permitted to occur in this case”.

The structures that govern prison healthcare, and the ways in which the prison health system is kept separate from the public healthcare system, largely immune from scrutiny and accountability, further entrench punitive models of care. In addition, privatised prison healthcare systems, such as those in Victoria, are incentivised to prioritise profits over health and wellbeing. The result is unsurprising — poor quality healthcare and a lack of accountability directly leads to more deaths in custody.

The punitive model of healthcare

In Veronica’s inquest, a panel of medical experts, as well as the Coroner, found that the model of healthcare at Dame Phyllis Frost Centre was a “punitive” form of care, where both medical practitioners and guards were reluctant to provide appropriate medical assistance and treatment.

While Veronica did everything she could to be heard, she was continually ignored, to the point of dehumanisation. In the inquest, Wiradjuri Professor Megan Williams described Veronica’s “continued disempowerment” as her active and clear requests went unanswered. She described the system as one in which there was “no access to healthcare”, and as one which left Veronica “culturally and spiritually isolated”.

The fact that Veronica was neglected by so many prison guards, doctors and nurses speaks to the systemic nature of the problem. Countless coronial inquests into First Nations deaths in custody document refusals or reluctance to provide basic medical treatment and care.

In 2017, Kamilaroi man Eric Whittaker passed away at 35 from a ruptured cerebral artery aneurysm after guards dismissed his 20 calls for help over his cell’s intercom. During the hours that his calls went unanswered, Eric shouted out in distress and panic and sobbed, asking for someone to please help him.

In 2018, 36-year-old Aboriginal man Nathan Reynolds passed away after prison staff failed to treat a severe asthma attack as an emergency. The Coroner found that although Nathan was experiencing a medical crisis, “the response he received … was confused, uncoordinated and unreasonably delayed”. His family said “[i]t was never any secret that Nathan was asthmatic”, however, “he was given no consistent, ongoing care for it”.

In 2014, 22-year-old Yamatji woman Ms Dhu died in police custody in South Hedland, Western Australia from a broken rib and severe case of pneumonia. During her detention, police and medical staff dismissed her cries for help. They thought she was “faking” her injuries or “exaggerating”.

Over 35 years ago, the Royal Commission into Aboriginal Deaths in Custody found that Nita Blankett, an Aboriginal mother of five, could have survived an asthma attack in prison if she had been provided prompt medical care. The Commission found “[a]lthough the deceased had complained that she was ill, appeared distressed and asked for a doctor and an ambulance, those responsible failed to understand, or they underestimated, the severity of her asthma attack”. Even when they did finally act, there was still a 30-minute delay for the prison van to exit the prison.

Stigma and racism within the prison healthcare system, both on an individual and systemic level, entrenches the view that people in prison are undeserving of care.

Dr Amanda Porter provided expert evidence to Veronica’s inquest that barriers facing Aboriginal women in prison to access healthcare include “institutional racism and discrimination in the form of not being listened to, stereotyping, and inequitable healthcare”.

Expert witness, Professor Carla Treloar told the inquest that racist stereotypes are compounded by stigma against drug users. Kylie Bastin, an Aboriginal woman in prison who tried to help Veronica, told the inquest about the stigma experienced by drug users in the prison system. She said “we’re all looked upon as scum” and “they treat us just as junkies” (Aboriginal Legal Service (NSW/ACT), 2021).

Along with other interested parties and experts, we argued that both racism and stigma against drug users — which both have deep roots in Australia’s carceral system — explained why Veronica’s repeated cries went unanswered.

In Veronica’s inquest, guards estimated 50–90% of women entering prison were withdrawing. Despite this, specialist care for withdrawal was lacking. Although Veronica had asked to be treated with methadone — a form of opiate substitution therapy available in the community — this request was denied. She was issued a set of standard medications that forced her into rapid withdrawal.

Kylie Bastin told the inquest about the pain involved in forced rapid withdrawal. Opioid withdrawal can cause severe vomiting that is capable of leading to fatal electrolyte imbalances. Simple medical intervention can prevent this. Veronica’s death was caused, at least in part, by the failure to provide her with medical care for withdrawal.

The Coroner found that there was a “punitive approach to the provision of pharmacotherapy” for treating addiction, whereby people in prison were punished through being denied opioid replacement therapy. This meant that people in prison for short periods of time, like Veronica, were forced into painful involuntary withdrawal.

While Veronica was forced, in her cell, to endure this pain and suffering, her steadily escalating medical emergency was dismissed by guards and nurses as withdrawal — a condition they did not think required medical attention. The Coroner found that Veronica’s treatment reflected stigma against drug users. This stigma led to an absence of care and causally contributed to her passing.

While the Coroner did not find racism, there is clear evidence that First Nations people are more likely to receive inadequate medical care in prison.

Research we presented to the Coroner from Professor Thalia Anthony showed that out of the deaths in custody of Aboriginal women investigated by the Royal Commission, 91% had inadequate assessments or health responses. While the most common cause of deaths in custody is medical issues, First Nations people who die in custody are three times more likely to not receive all required medical care prior to passing. For First Nations women, the result is even worse — less than half receive required medical care prior to death.

Keeping prison healthcare behind the prison wall

There are many different facets of prison healthcare that keep it separate from healthcare outside of prisons. These include its governance, culture and lack of accountability.

In prisons, healthcare practitioners face a conflict between their duty to preserve patient health and wellbeing, and their obligation to follow prison policies and rules that exist to manage, surveil and punish.

There is no Medicare or Pharmaceutical Benefits Scheme (PBS) behind bars. Prison policies restrict access to prescription medication otherwise available in the public system. Patients don’t get confidentiality when forced to rely on guards to convey medical information. Timely provision of care cannot be achieved where medical staff cannot unlock cells. Medical staff in prisons are frequently compelled to report to, and respond to the demands of, corrections staff.

Prison healthcare in many states, including Victoria and Western Australia, is managed by justice departments, rather than health departments. This further reinforces the predominance of the prison logic in healthcare provision, and conflicts with advice from the World Health Organisation and United Nations, which emphasises that prison healthcare should be part of a country’s general health services.

In Victoria, prison healthcare in public prisons is outsourced to for-profits who frequently change corporate structures to avoid accountability. At the time of Veronica’s passing, Correct Care provided healthcare at Victoria’s public and youth prisons. After Veronica’s passing, the contract went to GEO Group Australasia, the former parent company of Correct Care. Following years of advocacy, in July last year we had a huge victory — prison healthcare at women’s prisons was transferred to public providers. Healthcare in men’s public prisons remains in private hands.

It’s not only Victoria that relies on for-profit prison healthcare. Australia has the highest rate of private incarceration in the world — even higher than the United States — with companies like Serco, G4S and GEO Group raking in over $600 million per year. In these private prisons, prison healthcare is managed and provided by the same prison profiteers responsible for the prison.

It may seem obvious to most that a corporation with the core purpose of making profits rather than healing patients is going to provide worse-quality care. This is why many states in the US, including New York and Massachusetts, don’t allow for-profit hospitals or healthcare. Studies consistently show that prisons with private healthcare providers have higher numbers of deaths in custody.

That’s not to say that public healthcare providers always provide high-quality care — many don’t. Ruth Wilson Gilmore describes private prison operators as “parasites”, who exist “in the wake of an entire criminalisation project rather than being the people who make it happen”. It is the criminalisation project itself, which sees people as dispensable, that facilitates the medical neglect of people in prison.

However, the prioritisation of profits over patient health means that corporations are incentivised to increase profits, cut costs, expand to new carceral settings, and protect their multi-million-dollar contracts. In the US, internal documents uncovered from private prison healthcare providers quote “reduced sentences and decriminalisation” as “top business risks” (McLeod 2019).

The prioritisation of profits also incentivises these corporations to cover up their failings. After Veronica’s passing, a regional manager of Correct Care was found to have taken statements from relevant witnesses, but not from nurse Stephanie Hills, a critical witness in the inquest who became a whistleblower. Such egregious behaviour is perhaps unsurprising given Correct Care risked losing $700 million in contracts with the Victorian government.

Impunity for neglect

One year after the Coroner’s findings, prosecutors have filed no charges, no individual has been sanctioned, and there is still no independent scrutiny of prison healthcare. Well-paid bureaucrats say they have fixed the problem by implementing a new policy — not that anyone on the ground knew about the old one — and we still receive daily calls from people in prison who are denied basic medical care.

There is little that can be done behind bars to hold bad actors to account. In most states, there is no prisoners’ legal service that people in prison can go to when they receive neglectful healthcare. Aboriginal Legal Services like VALS (the Victorian Aboriginal Legal Service) and other community legal centres can only meet this need for small segments of the prison population.

Even after a death in custody, senior bureaucrats bend over backwards to cover up the State’s wrongdoing. Following Veronica’s passing, not only did internal government reviews find no serious failings in her care, but they praised people such as Tracey Brown, the guard responding to Veronica’s intercom calls on her final night.

Coronial inquests are not mandatory where a death is determined to be due to “natural causes”, a nebulous term with no precise definition. As stated by Gomeroi writer and legal scholar Alison Whittaker, this term suggests that those who die are “tragic and deserving figures, fated to die” — pathology becomes a way to avoid blame.

While governments often state they will implement changes called for by Coroners, there is little accountability when they fail to do so.

Following Veronica’s inquest, the Victorian government devised a new “Justice Health Quality Framework”. Despite our repeated requests, they have not told us how their new policy will lead to changes on the ground that would have prevented Veronica’s death.

As stated by Dr Amanda Porter in Veronica’s inquest, “hollow words and hollow promises”, including a “culture of denial, of not hearing and of impunity”, are part of the problem.

Where to from here?

The idea of a prison healthcare system which is safe, and supports the highest attainment of health and wellbeing, is a contradiction in terms. In Australia, we have over two hundred years of evidence to tell us that prisons are unsafe and deadly places, particularly for First Nations. The only way to see an end to deaths in custody and medical neglect in prisons is to work towards ending our reliance on prisons — which do nothing to keep us safe.

But there are changes to prison healthcare which can get us closer to this abolitionist goal. Breaking down barriers and not treating prisoners and the healthcare they receive as separate from society — as disappeared — not only improves the health and wellbeing of people who go in and out of prison but also gets us one step closer to breaking down prison walls.

Integrating prison healthcare systems with the public system includes transferring responsibility away from Corrections, departments of justice and for-profits, and towards health departments. It includes enabling people to access Medicare services and PBS medications. It also includes having medical professionals in prisons who also work across the public healthcare system.

Central to having a safe healthcare system for First Nations people is that healthcare be culturally safe. That means having access to Aboriginal Community Controlled Health Organisations, which centre First Nations cultures and definitions of health.

These steps would go some way towards enabling healthcare in prisons to be independent of the punitive correctional system.

There must also be real accountability for deaths in custody and medical neglect in prisons. As Uncle Percy said, “I want everyone to remember what happened to Veronica … and to change. No-one should have to die in prison. No-one should die in pain. No-one should die alone in a prison cell”.

I thank Veronica’s family for allowing me to share her story, in particular Uncle Percy Lovett, who I walk alongside in his fight for justice for Veronica. Veronica Nelson should be alive today, sharing in community and culture. I also thank Professor Megan Williams (Wiradjuri) for sharing her expertise on prison healthcare and cultural safety, and for her guidance in this essay.

References and resources

Aboriginal Legal Service (NSW/ACT), 2021, Inquest into Nathan Reynolds’ Death in Custody Comes to and End

AHPRA, Code of Conduct

“Following the Money: the Privatisation of Australian  Prisons”, 2021

Indigenous Law Resources, Nita Blankett: Synopsis

McLeod, M 2019, “The Private Option”, The Atlantic, 12 September

Szep, J et al, 2020, Special Report: US Jails Are Outsourcing Medical Care – and the Death Toll Is Rising, Reuters

UNODC, The United Nations Standard Minimum Rules for The Treatment of Prisoners [the Nelson Mandela Rules]

UNODC, Good Governance for Prison Health in the 21st Century, 2013

World Health Organisation, Europe, Declaration on Prison Health as Part of Public Health, 2004

[1] Dr Runacres is currently appealing some of these findings in the Supreme Court. That case will be heard on 31 October 2023.