In 2020, Veronica Nelson was found dead in her prison cell. She'd called out for help 49 times.

WARNING: Aboriginal and Torres Strait Islander readers are advised that the following article contains names and descriptions of people who have died.

In the early morning of January 2, 2020, prison staff found Veronica Nelson dead on the floor of her prison cell.

The 37-year-old proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman had been arrested in Melbourne just three days over shoplifting-related offences, and denied bail.

Locked up in Victoria's Dame Phyllis Frost Centre, Veronica was suffering an undiagnosed medical condition and drug withdrawal. 

In the 36 hours before her death, she cried out for help a total of 49 times. 

Watch: Footage from inside Veronica's cell. Post continues below.

Around 1am, Veronica reported experiencing leg cramps and was given Panadol and the anti-nausea drug Maxolon through a flap in the door.

In the hours following, she continued to call for help. 

As did other prisoners who heard her screams. 

But despite her pleas, prison and nursing staff did not check on Veronica physically, a 2020 hearing was told. 

Instead, they communicated with her through an intercom system and a door flap.

Veronica eventually declined an offer to be taken to the medical unit, saying she'd prefer to stay where she was.

Hours later, around 7.30am, she was found dead alone in her cell when she didn't respond to the morning head count. 

An autopsy later found Veronica was suffering from Wilkie’s syndrome, a rare medical condition that restricts the arteries.

The coronial inquest into Veronica Nelson's death. 

Three years later, a coroner has found Veronica endured "cruel and degrading" treatment from corrections staff, and her death was entirely "preventable". 

On Monday, coroner Simon McGregor delivered his findings following a five-week colonial inquest, where he handed down 39 recommendations, including an urgent review of Victoria's bail act - widely known as the toughest in the country.

"Veronica was loved and respected by those that knew her, yet Veronica, while alone in her cell at the Dame Phyllis Frost centre, passed away after begging for assistance for several of the last hours of her life," he said, as per the ABC.

"That Veronica was separate from her family, community, culture and country at the time of her passing is a devastating and demoralising circumstance."

McGregor also referred the prison's healthcare provider, Correct Care, to prosecutors for criminal charges because it failed to prevent a risk to the health and safety of non-employees.

Correct Care has acknowledged the coroner's findings and will review them, a spokesperson told AAP.

Corrections Victoria will also consider all recommendations and has already started to implement changes, according to Corrections Commissioner Larissa Strong.

Speaking after the coroner handed down his findings, Veronica's mother, Aunty Donna Nelson, said her daughter did not deserve to die in such a "cruel, heartless and painful way". 

"She should not have begged for her life, she should be here with me today," she said through tears.

"Her death never should have happened, I want you to fight with me and make sure that no other mother has to bury her child due to the racism and cruelty of a broken justice system."

Image: Supplied.

Veronica's partner of 20 years, Percy Lovett, said the 37-year-old should never have been in jail.

"The police officer arrested her even though she was just walking down the street minding her own business, she would not have been picked up if she was white - the police target us Blackfullas," he said.

"She was a kind and loving girl, who would always help people... if she were alive today we would still be together."

Speaking to the ABC, Lovett, who sat through the entire five-week inquest, said he still can't understand how those in the prison system missed the many opportunities to save Veronica's life.

"It was hard, listening to everything... just the way they let her die, you know, I can’t get over how people can be like that," he told the publication. 

"Everybody knows when someone’s in pain and when they’re lying and that, and the way they just sat there and let her go... all they had to do was their job, nothing else."

Larger issues at play. 

Veronica's story sadly isn't an isolated one.  

Over 500 Aboriginal and Torres Strait Islander people have died in custody since the 31 years since the Royal Commission into Aboriginal Deaths in Custody.

As of June 2021, Aboriginal and Torres Strait Islander prisoners made up more than a quarter - 30 per cent - of all prisoners, according to the ABS. 

On Monday, McGregor noted in the 12 months after Veronica's death, four more women died at the same jail, including one woman who was also Aboriginal or Torres Strait Islander. 

Victoria's bail laws. 

Ahead of the inquest, a parliamentary inquiry into Victoria’s criminal justice system recommended the state government review its bail laws, after changes led to an increase in the number of people on remand. 

The Legal and Social Issues Committee found the laws are impacting "women, particularly Aboriginal women and women experiencing poverty, the most."

Following the inquest, Victorian Premier Daniel Andrews flagged changes to the state's justice system, which will be introduced in the first half of the year.

On Tuesday, Andrews said his government had been working on a raft of changes for some time but they had not been fully discussed at cabinet.

The new changes will be a greater distinction between granting bail to violent and non-violent offenders and a bigger emphasis on prisoner welfare.

"Veronica Nelson should be alive today, she's not, for that we are truly sorry," he told reporters on Tuesday.

"We will not waste a moment in responding in full to the findings that the Coroner has handed down."

This article was originally published on April 27, 2022, and was updated on February 1, 2023.

Feature Image: Supplied.