Warning: this article contains the name and image of an Aboriginal person who has died and distressing content.
An Aboriginal woman's newborn baby was removed from her care soon after giving birth while in prison.
But Heather Calgaret was not given any mental health support after this traumatic event.
Over the next two years behind bars, the mother-of-four became obese, developed type 2 diabetes and suffered depression before being denied parole.
She died in custody in November 2021 after being given an inappropriately prescribed injectable opioid substitution.
Ms Calgaret's sister Suzzane, who was housed with her at the prison, found her struggling to breathe the following morning.
She shook Ms Calgaret to let her know it was time for the daily head count, but her younger sister was not moving.
A "code black" was called and she was taken to hospital, where she died four days later.
"When I went into the room and tickled her, I knew something was wrong, I knew her spirit was already gone," Suzzane said.
"That moment, I have to live with every day.
"Knowing that my sister didn’t turn her head or open her eyes to me."
Death was preventable
Countless missed opportunities to prevent the 30-year-old's death in custody were outlined by Victorian Coroner Sarah Gebert on Monday, as Ms Calgaret's family and supporters filled the courtroom.
"Not only was her passing preventable, she should never have passed in the manner that she did," the coroner said, as she delivered a 300-page finding.
The proud Yamatji, Noongar, Wongi and Pitjantjatjara woman was six months' pregnant when she arrived at Dame Phyllis Frost women's prison in July 2019.
The removal of her baby girl just after giving birth, because she had been denied access to the prison's Living with Mum program, was a pivotal moment, the coroner found.
"Heather had her other children removed ... and her family had been affected by the Stolen Generation," Ms Gebert said.
"Each of these factors would be expected to produce a range of both trauma-related symptoms and feelings of despair."
Ms Calgaret was not given access to a psychologist while at Dame Phyllis and her mental health declined.
About six months before her death, Ms Calgaret pleaded in a letter to be released on parole.
Pleading for release
She explained that the See Change program she was required to complete was not available at Dame Phyllis and asked to do it outside prison.
"I have four children that need me. I believe I have suffered enough," Ms Calgaret wrote in the letter.
She begged for someone to "please read and answer my letter", but it was never forwarded onto the parole board.
The coroner said Ms Calgaret had been eligible to be considered for parole more than a year earlier, about seven months after her sentence for aggravated burglary was imposed.
It wasn't until October 2021 – a month before she died – that she was told her parole application had been denied because of a lack of suitable accommodation.
On November 22, a prison doctor gave her a dosage of opiate replacement therapy that was too high for her tolerance level.
The Correct Care Australasia doctor had "lacked the careful consideration required" to prescribe the injectable drug, the coroner said.
She found Ms Calgaret would not have died if she had not been given the drug, or if she had been supervised afterwards.
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 outside court.
"There's a reason now for her passing and that reason has been justified by the outcome, but it doesn't bring her back."
Ms Gebert issued 16 recommendations, including monitoring women who give birth in custody for post-natal mental health treatment.
She encouraged Justice Health to work with the government and stakeholders to improve the psychological services available at the prison and their care of inmates with chronic health issues.
Ms Gebert said the parole application process should be reviewed to ensure it does not undermine the integrity of prison sentencing.
Victorian Aboriginal Legal Service acting chief executive Amanda Dunstall said Heather’s family had shown remarkable strength and courage throughout the past four years as they waited for answers.
“Part of the tragedy in today’s findings is that given the Allan Labor government’s current 'tough on crime approach' and abhorrent commitment to implementing regressive laws, there is no possibility that any of the coroner’s recommendations will be properly implemented," she said.
“Victoria’s parole process was found to be unfair to Aboriginal women, and is inconsistent with the right to equality in the Charter [of Victoria's human rights] and the right to Aboriginal self-determination.
"We know that sentencing and parole considerations for Aboriginal people are of critical importance and VALS is ready to work with the Department of Corrections, alongside the Aboriginal Justice Caucus to implement these recommendations immediately, alongside the outstanding recommendations from the Royal Commission into Aboriginal Deaths in Custody, and the Yoorrook Justice Commission.”
Ms Dunstall said the Victorian Corrections system is not designed to respond to the needs of Aboriginal women at Dame Phyllis Frost Centre prison and that ongoing lockdowns - where detainees are confined to their cells - are having a significant impact on mental health and wellbeing.
"My heart breaks for Heather and her children, especially her youngest who was removed from her as newborn while she was incarcerated," she said.
"Aboriginal women have not historically, and do not currently, have access to the ‘Living with Mum program’ at DPFC.
"The unnecessary trauma and suffering inflicted by removing her children and not providing adequate post-natal support is completely unacceptable.
"This was found to be a pivotal moment in Heather’s mental health decline in custody and it is harrowing."
The Victorian Aboriginal Community Controlled Health Organisation (VACCHO) is demanding that the Victorian Government urgently invests in a self-determined ACCO-led model of custodial health and wellbeing care for Aboriginal and Torres Strait Islander people in custody, as recommended by the coroner.
VACCHO chief executive Dr Jill Gallagher says the prison system continues to fail Aboriginal people and neglects to provide culturally safe and clinically adequate health and wellbeing care.
“How many more Aboriginal lives need to be lost before the Victorian government and the correction system is held to account? How many more reports and recommendations do we need calling for urgent action? Enough is enough!” Dr Gallagher said.
“Aboriginal-led care is the only solution to prevent more Aboriginal people from having their lives cut so devastatingly short.”
Coroner Gebert recommended that the Department of Corrections involve Aboriginal Community-Controlled Organisations in the design and delivery of holistic custodial services that are culturally safe and responsive to Aboriginal people, culture and rights.
“We know that placing healthcare in Aboriginal hands for Aboriginal people in custodial settings will break the cycles of harm," Dr Gallagher said.
"Through holistic, culturally appropriate health and wellbeing care, we can meet the needs of Aboriginal people in custody and consequently reduce the number of tragic deaths like Heather’s.”
Premier Jacinta Allan said it was a devastating case and that her thoughts and love were with Heather's family.
"We are already working with Aboriginal health organisations, we know we need to strengthen these supports and we will continue that work while we also consider the coroner's recommendations," she said.
In a statement Suzzane, Heather’s sister, and Aunty Jenny, Heather’s mother, thanked the coroner.
“Today doesn’t necessarily bring us peace about Heather’s passing because we already knew what had happened to her," they said.
"If anything, it has just reassured us.
"All we have left now are memories of Heather. We have her voice on the radio, the photos that will remind us that she was here and that she was alive ...
"Life really is precious.”
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