WARNING: Aboriginal and Torres Strait Islander readers are advised this story contains images of people who have died

The mother of an Aboriginal woman who died in custody cried as a Victorian coroner found her death was preventable.

The healthcare provider for a Victorian jail where Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman, Veronica Nelson died will be referred to prosecutors for criminal charges.

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The 37-year-old had been transferred to a regular cell after two days suffering severe opioid withdrawal on a medical ward.

But her repeated pleas were knocked back by prison guards and healthcare staff.

Coroner Simon McGregor on Monday declared Nelson’s death in January 2020 was preventable and called for bail law reform citing the adverse affects it had on First Nations people.

He will also refer the matter to the Department of Public Prosecution after finding CorrectCare, the health care provider for Dame Phyllis Frost Centre, failed to prevent a risk to the health and safety of non-employees.

“They did not apply clear processes and regulations, and I have a significant level of belief that an offence was committed,” he said.

His highly anticipated finding follows a five-week inquest, which ended in May last year.

Victoria’s bail laws are widely considered to be among the toughest in the country.

The state government made changes to the Bail Act in 2018 under expert advice in response to the 2017 Bourke Street massacre.

“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,” McGregor said.

He said prior to those changes Aboriginal and Torres Strait Islander people made up 8.2 per cent of the state’s prison population, and First Nations women were 10 per cent of female inmates.

But he number of Aboriginal women nearly doubled after the 2018 changes, McGregor said.

Of those, 61 per cent of unsentenced women were held on charges that did not involve violence.

McGregor also found that Victoria Police failed to consider Nelson’s Aboriginality and vulnerability, and violated her human rights.

Police argued she was an unacceptable risk to re-offend on bail and should not be granted bail.

McGregor said the remand summary was riddled with mistakes and was misleading.

Without legal representation for her bail application, Nelson did not challenge those claims, nor was she aware of her rights, the coroner said.

“Her journey through the criminal justice system occurred without her speaking to a single Aboriginal person employed in these roles,” he said.

He called for urgent bail reform, stating the “reverse onus regime incompatible with human rights”.

Nelson was arrested on December 30, 2019, on warrants for breaching bail and suspicion of shoplifting.

Following her 49 calls for help, Nelson was found dead in her cell at Dame Phyllis Frost Centre on January 2.

She died from complications of Wilkie’s syndrome, in a setting of withdrawal from heroin.

The coroner found corrections had failed to provide her with adequate healthcare.

After pressure from Nelson’s family and legal advocates, Attorney-General Jaclyn Symes last week confirmed changes to the laws were being discussed.

Nelson’s mother, Aunty Donna Nelson, sat in the front row of the court wearing a possum skin cloak and wiped away tears throughout the hearing.

The court room was filled with family and supporters, many from Shepparton and Narrandera in NSW, wearing “Justice for Veronica Marie Nelson” T-shirts and others wearing traditional face paint.