The coroner’s report into Nelson’s death has paved the way for changes to the way Indigenous Victorians are treated by the criminal justice system.

McGregor,who was brought to tears duringa four-hour-long reading of his findings,took aim at a litany of systemic failures within the criminal justice,health and corrections systems he said led to Nelson’s preventable death in inhumane and degrading circumstances.

Taking aim at the failure of the government to implement the recommendations of the Royal Commission into Aboriginal Deaths in Custody,McGregor said if this had been done 30 years ago,Nelson would still be alive today.

He said from the time of her arrest on December 30,2019,to her death four days later at a women’s prison,Nelson was culturally isolated and her human rights repeatedly breached.

“Veronica was loved and respected by those who knew her. Yet,Veronica,while alone in a cell at the Dame Phyllis Frost Centre,passed away after begging for assistance for several of the last hours of her life,” McGregor said.

“She was found the next morning on the floor of a cell in a prison built on the lands of the Wurundjeri and Bunurong people.

“That Veronica was separated from her family,community,culture and Country at the time of her passing is a devastating and demoralising circumstance.”

The Premier said on Tuesday the government would seek advice on all the coroner’s recommendations and expects to overhaul processes and work cultures,not just the law.

“The death of Veronica Nelson is a terrible tragedy,and one that will see significant reform and change,” Andrews said.

“The greatest and most respectful thing we can do by way of condolence and grief and empathy with the Nelson family is to get on and do the hard work of making these changes and reforms and also making sure our systems and processes operate as they should when a prisoner is sick,they get health care.

“When a prisoner is an Indigenous Victorian,then those provisions that are specifically written for Indigenous Victorians are properly applied. The list goes on.”

Nelson was arrested in Spencer Street on December 30,2019,and taken to a nearby police station for questioning on suspicion of shoplifting. But instead of being released on bail,she was transferred to Melbourne Magistrates’ Court where she was placed on remand until a court date weeks later.

Over the following two days,she made 49 calls for help over the prison’s intercom while heroin withdrawal and an undiagnosed medical condition ravaged her body.

She was found dead in her cell on January 2,2020,lying in the fetal position. Ambulance officers believe she had been dead for some time.

An autopsy found Nelson had undiagnosed Wilkie’s syndrome,a rare but potentially life-threatening gastrointestinal condition.

McGregor referred the actions of Correct Care Australasia to the Director of Public Prosecutions for investigation.

“I also find that Justice Health failed to ensure that Correct Care Australia delivered a standard of health ... and this failing causally contributed to her passing,” McGregor said.

“Veronica’s death was preventable.”

Attorney-General Jaclyn Symes thanked the coroner and said the government would carefully consider his recommendations.

“We know we need to do more in relation to criminal justice reform,including bail reform,and that work is continuing,” she said.

Images contained in this story were released to the media with permission from the family. Crisis support run by Aboriginal and Torres Strait Islander people,contact 13YARN (13 92 76).

The Morning Edition newsletter is our guide to the day’s most important and interesting stories,analysis and insights.Sign up here.