A Victorian coroner has recommended significant improvements to healthcare services provided in prisons following an investigation into the death of Heather Calgaret, a 30-year-old woman who identified with the Yamatji, Pitjantjatjara, Noongar, and Wongi communities. Calgret died in November 2021 after being found unconscious in her cell at Dame Phyllis Frost prison, where her sister Suzzane was also incarcerated at the time.
Coroner Sarah Gebert’s findings indicated that Calgaret had been inappropriately prescribed an opiate replacement therapy by prison health staff, which likely led to respiratory failure and her subsequent death. Calgaret, who was six months pregnant, had been remanded in custody in 2019 and had her parole application denied the month before her death.
Gebert recognized that while the parole decision was not the direct cause of Calgaret’s death, it highlighted significant issues in how parole applications are handled. The decision to deny parole was due to concerns about her housing arrangements, despite her mother’s address being included in her application as suitable accommodation.
Outside court, Suzzane Calgaret welcomed the findings but noted that such changes should have been implemented before her sister’s death. “I hope they have learned from this because it has cost my sister’s life,” she stated. “There is now a reason for her passing and although this outcome is justified, it doesn’t bring her back.”
The investigation also revealed that another Aboriginal woman, Veronica Nelson, had died at the prison while Calgaret was incarcerated. On the day of her sentencing in May 2020, Calgaret was given a two-year and three months’ jail term for armed robbery and six months for making a threat to inflict serious injury, with a non-parole period of 14 months.
Upon admission to prison, Calgaret was relatively healthy but over the next two years, she gained a significant amount of weight, became morbidly obese, and suffered from poorly controlled type 2 diabetes and liver issues. Her health declined further when her application to care for her baby in custody was denied.
The inquest drew attention to the lack of Aboriginal health workers at the time, despite having frameworks and policies for better healthcare delivery. It became clear that these policies were not effectively implemented in Calgaret’s case.
The Covid-19 pandemic further impacted the delivery of health services, as prisoners were locked down. The investigation focused on healthcare provision, parole management, opiate replacement therapy prescription, emergency care post-collapse, and the cause of death.
Gebert made 16 recommendations, including improved screening for postnatal mental health for women who give birth in custody, better monitoring of prisoner weight gain, increased access to psychological services at Dame Phyllis, and regular pharmacological reviews. Additionally, she recommended the Department of Justice and Community Safety investigate its parole application process to ensure it is consistent with efforts to reduce the overrepresentation of Aboriginal and Torres Strait Islander people in custody.
Source: https://www.theguardian.com/australia-news/2025/jul/29/inquest-into-aboriginal-woman-heather-calgarets-death-in-custody-urges-overhaul-of-victorias-prison-healthcare-ntwnfb
