Warning: this article contains the name and image of an Indigenous person who has died, and may be distressing for some readers.
A two-year investigation into the 2020 death in custody of Veronica Nelson has not recommended any charges be laid in the case.
The Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman died in January of that year at the maximum security Dame Phyllis Frost Centre prison, after her agonised pleas for help were ignored.
The prison's healthcare provider, Correct Care Australasia, and the state's Department of Justice and Community Safety became the subject of an inquiry in May 2022.
On Thursday, WorkSafe Victoria, which examined whether there were any breaches of the Occupational Health and Safety Act, said there was "insufficient evidence" to place charges against the institutions or officials involved.
Ms Nelson's mother, Aunty Donna Nelson, said
"My heart breaks," she said.
"I can't express to you the pain of seeing the people responsible for my daughter's death walk away unpunished.
"What good is the coronial process, the pain and heartache that we have to go through, if they just let these people walk?
'Cruel and degrading'
"They're killing our children and not holding anyone to account. It's painful. It's hurtful."
Ms Nelson was arrested in December 2019 on warrants for breaching bail and suspicion of shoplifting.
She represented herself in a bail application, which was denied.
Following dozens of calls for help, she died in her cell at Dame Phyllis Frost Centre days later from complications of Wilkie's syndrome, in a setting of withdrawal from heroin.
But the 37-year-old's repeated pleas were knocked back by prison guards and healthcare staff.
The coroner who examined Ms Nelson's death said it was preventable and called for bail law reform citing the adverse effects it had on First Nations people.
"I find that the Bail Act has a discriminatory impact on First Nations people, resulting in grossly disproportionate rates of remand in custody, the most egregious of which affect alleged offenders who are Aboriginal and/or Torres Strait Islander women," said Coroner Simon McGregor.
Ms Nelson's death would eventually result in serious changes to Victoria's bail laws, though not before the government was excoriated by the family for its delay in implementing them.
