'Doesn't bring her back': death in custody preventable

The Advertiser

2 days ago

An Aboriginal woman's newborn baby was ripped from her arms soon after giving birth while in prison.
But Heather Calgaret was not given any mental health support after this traumatic event.
Over the next two years behind bars, the mother-of-four became obese, developed type 2 diabetes and suffered depression before being denied parole.
She died in custody in November 2021 after given an inappropriately prescribed injectable opioid substitution.
Countless missed opportunities to prevent the 30-year-old's death in custody were outlined by a coroner on Monday, as her family and supporters filled the courtroom.
"Not only was her passing preventable, she should never have passed in the manner that she did," Victorian coroner Sarah Gebert said as she delivered a 300-page finding.
The proud Yamatji, Noongar, Wongi and Pitjantjatjara woman had been six months' pregnant when she arrived at Dame Phyllis Frost women's prison in July 2019.
The removal of her baby girl just after giving birth, because she had been denied access to the prison's Living with Mum program, was a "pivotal" moment, the coroner found.
"Heather had her other children removed ... and her family had been affected by the Stolen Generation," Ms Gebert said.
"Each of these factors would be expected to produce a range of both trauma-related symptoms and feelings of despair."
Ms Calgaret was not given access to a psychologist while at Dame Phyllis and her mental health declined.
About six months before her death, Ms Calgaret pleaded in a letter to be released on parole.
She explained the See Change program she was required to complete was not available at Dame Phyllis and asked to do it outside prison.
"I have four children that need me. I believe I have suffered enough," Ms Calgaret wrote in the letter.
She begged for someone to "please read and answer my letter", but it was never forwarded onto the parole board.
The coroner said Ms Calgaret had been eligible to be considered for parole more than a year earlier, about seven months after her sentence for aggravated burglary was imposed.
It wasn't until October 2021 - a month before she died - that she was told her parole application had been denied because of a lack of suitable accommodation.
On November 22, a doctor gave her a dosage of opiate replacement therapy that was too high for her tolerance level.
Ms Calgaret's sister Suzzane, who was housed with her at the prison, found her struggling to breathe the following morning.
She shook Ms Calgaret to let her know it was time for the daily count, but her younger sister was not moving.
A "code black" was called and she was taken to hospital where she died four days later.
The Correct Care Australasia doctor had "lacked the careful consideration required" to prescribe the injectable drug, the coroner said.
She found Ms Calgaret would not have died if she had not been given the drug, or if she had been supervised afterwards.
Suzzane Calgaret welcomed the findings but said it should not have taken her sister's death for changes to be made.
"I hope they just have learned from this because it's taken my sister's life, my mum's daughter's life," she said outside court.
"There's a reason now for her passing and that reason has been justified by the outcome, but it doesn't bring her back."
Ms Gebert issued 16 recommendations, including monitoring women who give birth in custody for post-natal mental health treatment.
She encouraged Justice Health to work with the government and stakeholders to improve the psychological services available at the prison and their care of inmates with chronic health issues.
Ms Gebert said the parole application process should be reviewed to ensure it does not undermine the integrity of prison sentencing.
13YARN 13 92 76
Lifeline 13 11 14
An Aboriginal woman's newborn baby was ripped from her arms soon after giving birth while in prison.
But Heather Calgaret was not given any mental health support after this traumatic event.
Over the next two years behind bars, the mother-of-four became obese, developed type 2 diabetes and suffered depression before being denied parole.
She died in custody in November 2021 after given an inappropriately prescribed injectable opioid substitution.
Countless missed opportunities to prevent the 30-year-old's death in custody were outlined by a coroner on Monday, as her family and supporters filled the courtroom.
"Not only was her passing preventable, she should never have passed in the manner that she did," Victorian coroner Sarah Gebert said as she delivered a 300-page finding.
The proud Yamatji, Noongar, Wongi and Pitjantjatjara woman had been six months' pregnant when she arrived at Dame Phyllis Frost women's prison in July 2019.
The removal of her baby girl just after giving birth, because she had been denied access to the prison's Living with Mum program, was a "pivotal" moment, the coroner found.
"Heather had her other children removed ... and her family had been affected by the Stolen Generation," Ms Gebert said.
"Each of these factors would be expected to produce a range of both trauma-related symptoms and feelings of despair."
Ms Calgaret was not given access to a psychologist while at Dame Phyllis and her mental health declined.
About six months before her death, Ms Calgaret pleaded in a letter to be released on parole.
She explained the See Change program she was required to complete was not available at Dame Phyllis and asked to do it outside prison.
"I have four children that need me. I believe I have suffered enough," Ms Calgaret wrote in the letter.
She begged for someone to "please read and answer my letter", but it was never forwarded onto the parole board.
The coroner said Ms Calgaret had been eligible to be considered for parole more than a year earlier, about seven months after her sentence for aggravated burglary was imposed.
It wasn't until October 2021 - a month before she died - that she was told her parole application had been denied because of a lack of suitable accommodation.
On November 22, a doctor gave her a dosage of opiate replacement therapy that was too high for her tolerance level.
Ms Calgaret's sister Suzzane, who was housed with her at the prison, found her struggling to breathe the following morning.
She shook Ms Calgaret to let her know it was time for the daily count, but her younger sister was not moving.
A "code black" was called and she was taken to hospital where she died four days later.
The Correct Care Australasia doctor had "lacked the careful consideration required" to prescribe the injectable drug, the coroner said.
She found Ms Calgaret would not have died if she had not been given the drug, or if she had been supervised afterwards.
Suzzane Calgaret welcomed the findings but said it should not have taken her sister's death for changes to be made.
"I hope they just have learned from this because it's taken my sister's life, my mum's daughter's life," she said outside court.
"There's a reason now for her passing and that reason has been justified by the outcome, but it doesn't bring her back."
Ms Gebert issued 16 recommendations, including monitoring women who give birth in custody for post-natal mental health treatment.
She encouraged Justice Health to work with the government and stakeholders to improve the psychological services available at the prison and their care of inmates with chronic health issues.
Ms Gebert said the parole application process should be reviewed to ensure it does not undermine the integrity of prison sentencing.
13YARN 13 92 76
Lifeline 13 11 14
An Aboriginal woman's newborn baby was ripped from her arms soon after giving birth while in prison.
But Heather Calgaret was not given any mental health support after this traumatic event.
Over the next two years behind bars, the mother-of-four became obese, developed type 2 diabetes and suffered depression before being denied parole.
She died in custody in November 2021 after given an inappropriately prescribed injectable opioid substitution.
Countless missed opportunities to prevent the 30-year-old's death in custody were outlined by a coroner on Monday, as her family and supporters filled the courtroom.
"Not only was her passing preventable, she should never have passed in the manner that she did," Victorian coroner Sarah Gebert said as she delivered a 300-page finding.
The proud Yamatji, Noongar, Wongi and Pitjantjatjara woman had been six months' pregnant when she arrived at Dame Phyllis Frost women's prison in July 2019.
The removal of her baby girl just after giving birth, because she had been denied access to the prison's Living with Mum program, was a "pivotal" moment, the coroner found.
"Heather had her other children removed ... and her family had been affected by the Stolen Generation," Ms Gebert said.
"Each of these factors would be expected to produce a range of both trauma-related symptoms and feelings of despair."
Ms Calgaret was not given access to a psychologist while at Dame Phyllis and her mental health declined.
About six months before her death, Ms Calgaret pleaded in a letter to be released on parole.
She explained the See Change program she was required to complete was not available at Dame Phyllis and asked to do it outside prison.
"I have four children that need me. I believe I have suffered enough," Ms Calgaret wrote in the letter.
She begged for someone to "please read and answer my letter", but it was never forwarded onto the parole board.
The coroner said Ms Calgaret had been eligible to be considered for parole more than a year earlier, about seven months after her sentence for aggravated burglary was imposed.
It wasn't until October 2021 - a month before she died - that she was told her parole application had been denied because of a lack of suitable accommodation.
On November 22, a doctor gave her a dosage of opiate replacement therapy that was too high for her tolerance level.
Ms Calgaret's sister Suzzane, who was housed with her at the prison, found her struggling to breathe the following morning.
She shook Ms Calgaret to let her know it was time for the daily count, but her younger sister was not moving.
A "code black" was called and she was taken to hospital where she died four days later.
The Correct Care Australasia doctor had "lacked the careful consideration required" to prescribe the injectable drug, the coroner said.
She found Ms Calgaret would not have died if she had not been given the drug, or if she had been supervised afterwards.
Suzzane Calgaret welcomed the findings but said it should not have taken her sister's death for changes to be made.
"I hope they just have learned from this because it's taken my sister's life, my mum's daughter's life," she said outside court.
"There's a reason now for her passing and that reason has been justified by the outcome, but it doesn't bring her back."
Ms Gebert issued 16 recommendations, including monitoring women who give birth in custody for post-natal mental health treatment.
She encouraged Justice Health to work with the government and stakeholders to improve the psychological services available at the prison and their care of inmates with chronic health issues.
Ms Gebert said the parole application process should be reviewed to ensure it does not undermine the integrity of prison sentencing.
13YARN 13 92 76
Lifeline 13 11 14
An Aboriginal woman's newborn baby was ripped from her arms soon after giving birth while in prison.
But Heather Calgaret was not given any mental health support after this traumatic event.
Over the next two years behind bars, the mother-of-four became obese, developed type 2 diabetes and suffered depression before being denied parole.
She died in custody in November 2021 after given an inappropriately prescribed injectable opioid substitution.
Countless missed opportunities to prevent the 30-year-old's death in custody were outlined by a coroner on Monday, as her family and supporters filled the courtroom.
"Not only was her passing preventable, she should never have passed in the manner that she did," Victorian coroner Sarah Gebert said as she delivered a 300-page finding.
The proud Yamatji, Noongar, Wongi and Pitjantjatjara woman had been six months' pregnant when she arrived at Dame Phyllis Frost women's prison in July 2019.
The removal of her baby girl just after giving birth, because she had been denied access to the prison's Living with Mum program, was a "pivotal" moment, the coroner found.
"Heather had her other children removed ... and her family had been affected by the Stolen Generation," Ms Gebert said.
"Each of these factors would be expected to produce a range of both trauma-related symptoms and feelings of despair."
Ms Calgaret was not given access to a psychologist while at Dame Phyllis and her mental health declined.
About six months before her death, Ms Calgaret pleaded in a letter to be released on parole.
She explained the See Change program she was required to complete was not available at Dame Phyllis and asked to do it outside prison.
"I have four children that need me. I believe I have suffered enough," Ms Calgaret wrote in the letter.
She begged for someone to "please read and answer my letter", but it was never forwarded onto the parole board.
The coroner said Ms Calgaret had been eligible to be considered for parole more than a year earlier, about seven months after her sentence for aggravated burglary was imposed.
It wasn't until October 2021 - a month before she died - that she was told her parole application had been denied because of a lack of suitable accommodation.
On November 22, a doctor gave her a dosage of opiate replacement therapy that was too high for her tolerance level.
Ms Calgaret's sister Suzzane, who was housed with her at the prison, found her struggling to breathe the following morning.
She shook Ms Calgaret to let her know it was time for the daily count, but her younger sister was not moving.
A "code black" was called and she was taken to hospital where she died four days later.
The Correct Care Australasia doctor had "lacked the careful consideration required" to prescribe the injectable drug, the coroner said.
She found Ms Calgaret would not have died if she had not been given the drug, or if she had been supervised afterwards.
Suzzane Calgaret welcomed the findings but said it should not have taken her sister's death for changes to be made.
"I hope they just have learned from this because it's taken my sister's life, my mum's daughter's life," she said outside court.
"There's a reason now for her passing and that reason has been justified by the outcome, but it doesn't bring her back."
Ms Gebert issued 16 recommendations, including monitoring women who give birth in custody for post-natal mental health treatment.
She encouraged Justice Health to work with the government and stakeholders to improve the psychological services available at the prison and their care of inmates with chronic health issues.
Ms Gebert said the parole application process should be reviewed to ensure it does not undermine the integrity of prison sentencing.
13YARN 13 92 76
Lifeline 13 11 14