‘Grossly inadequate’: Victoria’s flawed prison oversight regime

Victoria's "independent" prison inspectorate found no issues with the treatment of Veronica Nelson. A coroner said this was "grossly inadequate and misleading".

The government body tasked with providing “objective and honest” scrutiny of the Victorian justice system provided a “grossly inadequate and misleading” report on the death of Veronica Nelson in prison and should be “urgently” redesigned, a coroner has found.

The Justice Assurance and Review Office (JARO) sits within the Victorian Department of Justice and Community Safety (DJCS) and has an “internal review and assurance function to advise the secretary to the DJCS on the performance of youth justice and corrections systems”.

JARO lists its own aims as to drive “continuous improvement in Victoria’s critical justice system, making the systems better for the community, staff and people held within and visiting the justice facilities”. It claims to be “objective, impartial, fair and honest”.

But JARO’s flaws and failures have been put on stark display by the Coroner tasked with investigating the death of First Nations woman Veronica Nelson at the Dame Phyllis Frost Centre in early 2020.

Coroner Simon McGregor found that every step of Victoria’s criminal justice system failed Nelson, and that her death could and should have been prevented. He delivered a scathing assessment of Corrections staff and healthcare workers at the prison.

The Coroner also strongly criticised the role of JARO in investigating Nelson’s death in custody.

JARO finalised its report 10 months after the death in custody, based on the autopsy findings, CCTV footage and recordings of the intercom calls, the same calls featured heavily in the coronial inquest.

The JARO report accepted evidence put forward that a prison officer in question had performed their duties as expected, and made no criticisms of the patrols conducted by a prison officer who failed to directly observe Nelson in her final hours. The final JARO report found that the “incident response” was handled well. 

It also claimed that the management of Nelson was “appropriate and in line with Corrections Victoria policies”.

The coroner found the opposite.

The report also commended an officer who had placed a pillow over the grille of an adjacent cell for their “compassionate response”. But it did not mention that when this was done, Nelson’s body had been visible to the person in the adjacent cell through this grille for over 20 minutes.

The coroner ruled that JARO’s report on the death in custody was “grossly inadequate and misleading”.

He called for JARO to be “urgently redesigned” by the Victorian government to ensure its reviews are independent, that it receive input from relevant staff who interacted with or were responsible for decisions impacting the person’s death, identify opportunities for improved practice and enhancing the wellbeing of people in prison and also looks at the adequacy of care assessed by a suitable member of the Indigenous community.

JARO is the same body which will likely take on Victoria’s obligations under the United Nation’s Optional Protocol to the Convention Against Torture (OPCAT), which requires signatories to have independent inspection bodies for places of detention.

But the coroner’s report shows that JARO falls well short of the OPCAT requirements and significant reform will be needed to make it compatible.

The Victorian government is yet to make any moves to meet the OPCAT obligations, and is waiting on a funding commitment from the federal government until it does so.

Despite this, the government has repeatedly claimed that there are “robust oversight regimes in place to ensure that people in detention are protected against torture”.