A Victorian coroner has recommended wide-ranging improvements to healthcare provided in prisons after an inquest into the death of a 30-year-old Yamatji, Pitjantjatjara, Noongar and Wongi woman.
Heather Calgaret died in November 2021 after being found unresponsive in her cell at Dame Phyllis Frost prison by her sister Suzzane, who was also incarcerated at the time.
Coroner Sarah Gebert found that Calgaret had inappropriately been prescribed an opiate replacement treatment by prison health workers and that it likely triggered a respiratory failure which led to her death.
Calgaret was remanded in custody in 2019 while she was six months pregnant with her fourth child, and she had an application for parole denied the month before she died, though the parole system was beyond the scope of the inquest.
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Gebert found, however, that while this decision did not directly cause Calgaret’s death, it was important to consider issues related to determining parole applications.
There were “numerous issues of concern” identified with the management of Calgaret’s application, she found. Calgaret was denied parole because her housing was deemed unsuitable and there was insufficient time for her to find alternate accommodation.
This was despite her having placed her mother’s address on her parole application in May 2020, and Community Correctional Services not raising any concerns about this or raising any alternatives until September 2021, when it was deemed inappropriate.
“Whether and how a parole application progresses has the potential to impact on a person’s continuing incarceration and all that flows from being in the custody of the state,” Gebert found on Monday.
“I further noted that the continuing over-representation of Aboriginal people in custody also heightens the need for and significance of examining the issues that were included [in the inquest].”
Speaking outside court on Monday, Suzzane Calgaret welcomed the findings but said it should not have taken her sister’s death for changes to be made.
“I hope they just have learned from this because it’s taken my sister’s life, my mum’s daughter’s life,” she said.
“There’s a reason now for her passing and that reason has been justified by the outcome but it doesn’t bring her back.”
Gebert also noted that another Aboriginal woman, Veronica Nelson, died at the prison while Calgaret was in custody.
On 4 May 2020, Calgaret was sentenced to two years and three months’ imprisonment for armed robbery and six months’ imprisonment for “make threat to inflict serious injury” with a non-parole period of 14 months.
Gebert found that when Calgaret was admitted to prison, she weighed 95kg (though was six months pregnant) and was relatively healthy.
Within the next two years, she gained 70kg, was classified as morbidly obese, had poorly controlled type 2 diabetes, sustained “liver function derangement” and had likely obstructive sleep apnoea.
Gebert found that court experts identified that the removal of Calgaret’s daughter was a pivotal moment in her overall decline in health. Calgaret had an application to care for her baby in custody, under the Living with Mum Program, denied.
There were no Aboriginal health workers at the prison at the time, the coroner heard, but there were frameworks and policies in place which should have meant she was provided better care.
“I can only conclude therefore, that whilst there were robust health policies and commitments in place, it was apparent that the delivery of health services to Heather did not meet those aspirations in the crucial areas which have been highlighted,” Gebert found.
The Covid-19 pandemic affected the delivery of services and required prisoners to be locked down while Calgaret was imprisoned, the coroner found.
There were five primary areas of focus during the inquest, including the provision of healthcare, the management of Calgaret’s parole application, the prescription of opiate replacement therapy, the emergency care after her collapse and the cause of her death.
Gebert made 16 recommendations, including that Justice Health establish measures to ensure adequate screening and monitoring for postnatal mental health symptoms in women who give birth in custody or “proximate to their remand” and that they support women who are refused access to the Living with Mum program.
She also recommended that Justice Health better monitor prisoner weight gain, improve access to psychological services at Dame Phyllis, and work with providers to ensure regular pharmacological reviews, proper documentation of chronic healthcare plans and explore models for Aboriginal community health organisations to provide services to Aboriginal people in custody.
The Department of Justice and Community Safety should investigate how its parole application process is consistent with its commitment to reduce the over-representation of Aboriginal and Torres Strait Islander people in custody, Gebert recommended.