Victorian Aboriginal woman Heather Calgaret's death in custody was preventable, coroner finds

Australia Broadcast Center

28-07-2025

From behind bars, Heather Calgaret wrote to loved ones that she wanted to leave prison behind and become a "better person", to make her children proud.
NOTE: This story uses images of Heather Calgaret with the permission of her family.
"I look back with sadness rather than hate. I look forward with hope rather than despair," she wrote.
But the 30-year-old never got the chance to fulfil her dream of rebuilding a life in the community before her death in November 2021.
On Monday, coroner Sarah Gebert found that death was preventable and came after a litany of missed opportunities to support the Aboriginal woman's health in Melbourne's Dame Phyllis Frost prison.
"Not only was Heather's passing preventable, she should never have passed in the manner she did," Ms Gebert said.
The coronial inquest heard Heather was less than 10 weeks from completing a sentence for armed robbery when her sister Suzanne Calgaret, who was living in the same prison unit, was unable to rouse her ahead of the daily check-in.
Ms Gebert said after the alert was raised in the prison, Heather was rushed to Sunshine Hospital, but she had already suffered an irreversible brain injury.
The coroner found the passing of the Noongar, Yamatji, Wongi and Pitjantjatjara woman after respiratory failure was the preventable result of inappropriately prescribed medication the day before.
She found the doctor who prescribed the injection of the opioid substitution drug buprenorphine did not follow guidelines in place to ensure Heather would be able to tolerate the drug.
Heather had sought access to opioid substitution therapies because she wanted to ensure she would stay off drugs after her release from prison just weeks later, the inquest heard.
Ms Gebert said usually, a patient would receive another drug — suboxone — for five days before beginning treatment with buprenorphine, as a stabilising step.
In Heather's case, this did not happen because the doctor believed she had already been using suboxone in prison, relying on self-reported use by Heather. But the coroner found the doctor could not have been "reasonably satisfied" by this assumption.
Ms Gebert said the prescription of the injection of buprenorphine was therefore "inappropriate".
The court heard the departure from prescribing protocol was not communicated by the doctor to nurses, who may have otherwise been more vigilant in monitoring after treatment.
"I consider that but for the administration of [buprenorphine], Heather would not have passed," Ms Gebert said.
During the delivery of her findings, the at-times emotional coroner acknowledged the three other Aboriginal women who had been in the same prison unit with Heather, including her sister Suzanne.
"I acknowledge those women who supported each other and were each other's family during their incarcerations," she said.
"They unfortunately witnessed the unspeakable which occurred in their unit: the passing of a loved one and another death in custody.
'It is my hope that the manner in which Heather passed does not overshadow her spirit or her tremendous life of value."
In findings running to almost 300 pages, the coroner also identified "numerous issues" of concern relating to the way Heather's parole assessment was managed.
She recommended the agencies involved in Heather's journey through the justice system reflect on why the standards of care and fairness laid down in policies and called for by past commissions and the Yoorrook truth-telling inquiry had, at times, not been met.
Speaking before the findings were handed down, Heather's family told the ABC they were still struggling to process the loss of their "rock", who had filled their lives with love and laughter.
"She was the best older sister," her youngest brother Rory Smith said.
He said Heather had been going through a "rough time" when she went into prison — in part because child protection authorities had taken custody of her children — but that did not define her.
"Her kids were literally her world," he said.
"If she would have gotten parole she would still be here today."
In her findings, Ms Gebert noted an "insightful" letter written by Heather in which she put forward her case for parole.
In it, the mother of four noted that she had been told that in order to complete parole she needed to finish a rehabilitation program, but the prison was not running any sessions in the near future.
"I guess what I'm trying to say, is if Dame Phyllis is not running the See Change program, is there any possibility of completing this on the outside, in the community," Heather wrote.
The coroner said the inquest had heard there was a "cruel Kafkian circularity" in the requirement to complete a particular program to be eligible for parole, when no such program was available.
Ms Gebert said while parole was never guaranteed for prisoners, it was reasonable to expect that the justice system should be able to facilitate the sentences handed down by judges after close scrutiny of each individual case.
She also noted that Heather's suggestion that she could live with her mother was judged "unsuitable" during her parole assessment, but there was no evidence that authorities had previously raised concerns about the address.
While in prison, Heather gave birth to her fourth child and applied to have her baby live with her in the prison's mother-and-baby unit.
That application was rejected, in a decision that was not within the scope of the coronial inquest — although one expert told the court that allowing Heather and her child to remain together may offered an opportunity to break a cycle.
Heather's mother, Aunty Jenny Calgaret, said the decision by authorities to take Heather's newborn child from her would have "crushed" her.
"She was so excited when she was pregnant … she couldn't wait to have the baby and she was confident that she was going to keep the baby in the prison with her," Aunty Jenny said.
The coronial inquest heard that in the aftermath of the removal, Heather began self-medicating with food, gaining a significant amount of weight as her mental health declined.
Ms Gebert said the inquest had heard her condition required "urgent mental health treatment" that she was unlikely to get in prison.
"There were many missed opportunities throughout that time to intervene [on] Heather's health decline," she said.
During her time in prison, Heather turned to visual art to express herself, producing a series of paintings which she shared with family and sold through the not-for-profit Torch art program.
"She used to ring all the time and tell us, 'I sold another painting today'," Aunty Jenny said.
"I was really happy and proud for her."
Aunty Jenny said the vibrant compositions were now a reminder of her beautiful, funny daughter, who had been filled with laughter and love for her family.
"I see Heather. I see her, straight away. It's her all over," Aunty Jenny said.
After Monday's hearing, Heather's sister Suzanne said the family hoped lessons would be learnt to prevent similar deaths in future.
"[For prison health workers] to be aware of just how strong the opioids can be, especially for those who are on it and who do need it, it can happen to any which one of them," she said.
"Life is precious, that's what we all need to realise. Once you're gone, you're gone."
The Victorian Minister for Corrections has been contacted for comment.