Coronial inquest into Aboriginal woman Heather Calgaret's death in custody begins in Melbourne
By Sacha Payne and Joseph DunstanHeather Calgaret was a beloved mother, sister, daughter and friend. Her family says nothing will be the same without her.
Note: Heather Calgaret's family has given permission for her name and image to be used.
How the 30-year-old Yamatji, Noongar, Wongi and Pitjantjatjara woman's life ended will be examined in a four-week coronial inquest starting today.
Heather was months from completing a sentence for armed robbery at the Dame Phyllis Frost Centre in Melbourne's west when she died in November 2021.
She was living in a reintegration unit of the prison and had already submitted a parole application a year earlier, which had been rejected due to a lack of suitable accommodation.
In an earlier directions hearing, the Coroners Court of Victoria heard Heather had been given an injection of buprenorphine — an opioid medication used to treat drug addiction — a day before she was discovered unresponsive by her sister.
She was taken to Sunshine Hospital where she later died.
How that parole application was handled and the healthcare offered by prison staff will be in focus for the inquest.
Heather's death leaves family 'heartbroken' as inquest begins
Her brother, James "Chum" Smith read a statement outside the Coroner's Court in Melbourne ahead of Monday's hearing.
Surrounded by emotional family, friends and supporters, he described Heather as "the rock of our family".
"We were heartbroken by her death," he said.
"Life is precious, Heather's life is precious. It shouldn't have been taken away from her."
As the hearing began the music of Pitjantjara artist Frank Yamma, a relative of Heather's, filled the crowded courtroom.
The inquest heard Heather was a promising artist who loved her culture, which she connected to through her children and her art.
Upon reception at Dame Phyllis Frost, she was assessed as being in good mental and physical health, with no significant history of illness.
She was six months pregnant and was not on any medication, but she had been using cannabis and methamphetamines.
As she knew she was likely to be in prison when she gave birth, Heather applied to have her baby live with her in the prison's mother-and-baby unit.
However, shortly before the birth Heather was informed that her application had been denied and she was later discharged from the hospital without her baby.
The inquest heard that she was extremely traumatised after the birth and was not coping.
By the time she died she had been diagnosed with a number of chronic health conditions including obesity, diabetes, heart problems and depression, and had been prescribed six different medications, including an anti-depressant and anti-psychotics.
Four-week inquest will hear from witnesses and health experts
Over the next month, the inquest will hear from witnesses including other prisoners and prison staff.
It will also hear from expert witnesses in physical and mental health, including toxicologists, cardiologists and those involved in cultural care. The coronial brief includes 4,000 pages of documents.
Her family pointed out that Heather was born in 1991, the same year as the Royal Commission into Aboriginal Deaths in Custody released its recommendations, many of which have never been acted upon.
Coroner Sarah Gebert said many struggled to comprehend why tragic Indigenous deaths in custody continued to occur, despite numerous investigations.
She said the mental and physical health of prisoners should not deteriorate while in custody and there needed to be a focus on prevention.
Previous inquest on death at same prison called for sweeping changes
The Dame Phyllis Frost Centre is Victoria's only maximum-security women's prison, and is the same jail where Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman Veronica Nelson died in agony after a series of desperate calls for help from her cell.
The coroner examining Veronica's death found she endured "cruel and degrading" treatment before suffering a painful death that could have been prevented if prison staff had better responded to her repeated calls for help.
Amid public outrage over the treatment of Veronica, the Victorian government moved to transfer healthcare in women's prisons to the public sector from the middle of last year.
It means responsibility for the delivery of healthcare now sits under the health department instead of the justice department.
At the time of Heather and Veronica's deaths, healthcare at the Dame Phyllis Frost Centre was delivered by the US-owned, for-profit healthcare provider Correct Care Australasia.