Victoria, Australia coroner Simon McGregor Monday released a 366-page report calling for reforms to the Victoria Bail Act following the death of 37-year-old Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman Veronica Nelson in custody.McGregor outlined the failings of the police and private prison healthcare contractor Correct Care and Corrections Victoria. McGregor said Nelson’s death “would have been prevented if she had been transferred to hospital at any point between her arrest and her passing.” Nelson died alone in her cell in a Melbourne prison on January 2, 2020, after being arrested over shoplifting-related offenses. The medical cause of her death was determined to be “complications of Wilkie Syndrome in the setting of withdrawal from chronic opiate use,” including malnutrition, nausea and repeated vomiting.McGregor suggested section 3A of the Bail Act 1977, which dictates that a bail decision maker must consider “any issues that arise due to the person’s Aboriginality,” has not been used to its full force, while section 18AA should be ‘amended to allow two applications for bail before new facts and circumstances must be demonstrated’. It also recommended section 3AAA(1)(h) be amended to “expressly identify substance use disorders as included in the definition of ‘mental illness’ (but without requiring proof of a formal diagnosis).” Apart from overhauling bail laws, McGregor also urged the Victorian government to implement all recommendations from the 1991 royal commission into Aboriginal deaths in custody.Wiradjuri woman and professor Megan Williams explained that it is “[d]amaging for an Aboriginal person to pass away in an institution, in a colonised setting where Aboriginal people have very little power to shape that system to respond to our needs and to respond to our cultures[.]”A statement on behalf of Veronica Nelson’s family said Veronica did not deserve to die in such a “cruel, heartless and painful way.” Veronica’s mother Aunty Donna Nelson said:To the law makers, I want you to sit and listen to Veronica’s final hours. I want her voice to ring in your ears until you realise that our justice system is broken. Veronica should never have been locked up. You were supposed to change bail laws to stop a white male monster from killing people, but instead you filled our prisons with non-violent Aboriginal women like my daughter Veronica. Our bail laws need to change now.