Independent Review into implementation of recommendations from the Coronial Inquest into the passing of Veronica Nelson

Warning: Aboriginal and Torres Strait Islander readers are advised that this page contains references to Aboriginal people who have passed away, which may cause distress to some people. 

Veronica Marie Nelson (Veronica), a proud Gunditjmara, Dja Dja Warrung, Wiradjuri, and Yorta Yorta woman, sadly passed away in the State’s custody on 2 January 2020. She was remanded in custody at the Dame Phyllis Frost Centre (DPFC) at the time of her passing, having been refused bail for alleged relatively minor, non-violent offences. While in custody, she experienced opioid withdrawal and an undiagnosed condition, Wilkie Syndrome, linked to malnutrition. Despite asking for help many times, Veronica’s requests were often ignored, and her medical care was not escalated despite her showing signs of deterioration. Tragically, Veronica passed away in custody within three days of her arrest.  

Veronica’s treatment and passing led to a Coronial Inquest in 2022. The Commission intervened in the Inquest, providing guidance on how the Charter of Human Rights and Responsibilities Act 2006 (Vic) (Charter) applied to the Coroners Court and the human rights raised by the case.  

In January 2023, Coroner Simon McGregor released his Finding and made 39 recommendations. The Finding determined that Veronica’s passing could have been prevented, and that Veronica was not provided with adequate and culturally appropriate care while in custody. The Coroner also found that the circumstances surrounding Veronica’s passing unjustifiably limited her rights under the Charter, including her: 

• right to equality (section 8) 

• right to life (section 9) 

• right to be protected from cruel, inhuman and degrading treatment (section 10) 

• cultural rights as First Nations person (section 19) 

• right to humane treatment when deprived of liberty (section 22). 

As required by Inquest recommendation 39, the Commission will focus on changes to policies, programs and practices made by the Department of Justice and Community Safety’s (DJCS) Justice Health Unit (Justice Health) and Corrections Victoria at DPFC in response to specific recommendations of the Coroner.  

Recommendation 39: 

‘I recommend that no later than 12 months from the date of this Finding, Corrections Victoria, Justice Health and Correct Care Australasia, as public authorities under the Charter request that the Victorian Equal Opportunity and Human Rights Commission conduct a review under Section 41(c) of the Charter of any improvements to programmes, practises, and facilities made in response to the recommendations above, and provide an overview of the results of that review for publication on the Coroners Court of Victoria website along with the responses to the Recommendations made in this Finding.’ 

Section 41(c) of the Charter allows the Commission to conduct independent reviews when a public authority requests it.  

The DJCS and the Commissioner of Corrections Victoria have formally asked the Commission to review the relevant programs and practices of the DJCS Justice Health and Corrections Victoria.  

Justice Health is a part of the DJCS and is responsible for the delivery of health services to people in Victoria’s prisons. Corrections Victoria operates Victoria’s adult prison systems. Correct Care Australasia no longer provides healthcare services to DPFC and is not part of this Review.  

This Review will consider the Coroner’s recommendations 20, 21, 23, 24, 25, 26, 27, 28, 29, 33 and 37. These recommendations relate to policies, programs and practices to improve the health, welfare, wellbeing and safety, of people in custody, including Aboriginal cultural safety. 

The Commission will identify the changes to policies, practices and programs made by Justice Health and Corrections Victoria, based on the Coroner’s recommendations, and assess whether they are compatible with human rights. This analysis will extend to improvements made by the current contracted DPFC health service provider, Western Health, in response to changes required by Justice Health. 

To achieve this, the Commission will complete the following by 30 June 2026 

• Review key documents and policies, visit DPFC and engage with staff and leaders from Justice Health, Corrections Victoria and Western Health 

• Identify changes made to programs and practices in response to the Inquest recommendations 

• Analyse the extent to which these changes are compatible with human rights under the Charter 

• Develop any recommendations necessary to improve compliance with the Charter 

• Develop a publicly available report to be published on the Coroners Court of Victoria website  

In July 2025 the scope of the Review was broadened for the Commission to engage with Aboriginal and Torres Strait Islander people in custody at DPFC in relation to their lived experience and impacts of Coronial recommendations 23, 25, 26 and 29.1. As a result of this change, the Review report will be published in June 2026, rather than in March 2026 as was previously planned. 

As the Commission’s primary engagement will be with Justice Health and Corrections Victoria, the Commission will not seek public submissions for this Review. We will also engage with specific stakeholders, including First Nations health experts, to enable us to collect key information to deliver this Review.

The Commission recognises the importance of this Review. We hope that it will enhance human rights compliance in Victoria’s prison system. 

Review contact 

Independent Review Team 

independentreview@veohrc.vic.gov.au