An inquest into the death of an Aboriginal woman found unconscious in prison by her sister will examine Victoria's parole law and prison healthcare.
Heather Calgaret died at Sunshine Hospital in 2021 after her sister Suzzanne found her in a critical condition at Dame Phyllis Frost Centre Prison.
The Yamatji, Noongar, Wongi and Pitjantjatjara woman had been administered an opioid medicine a day prior to being found unresponsive.
She had also been eligible for parole for almost a year and was set to be released in February 2022.
Ms Calgaret submitted a parole application in May 2020, but was denied because she didn't have suitable accommodation.
An inquest into the mother-of-three's death will examine the quality and cultural appropriateness of healthcare provided in prison and the process of her parole application.
Coroner Sarah Gebert will look at whether an 8mg dose of buprenorphone, a medicine used to treat people with an opioid drug dependence, administered to Ms Calgaret a day before she was found unconscious contributed to her death.
Victoria needed to urgently review its health care system and overhaul the healthcare provided to people in custody, Victorian Aboriginal Legal Service lawyer Sarah Shwartz said.
The 10-month delay from when Ms Calgaret first became eligible for parole in December 2020 will be scrutinised after she submitted an application in May 2020, which was denied in October 2021 as well as support measures.
It would be the first time Victoria's parole laws had been examined since they were toughened by the state government almost a decade ago, Ms Schwartz said.
The Labor government reformed Victoria's parole system in 2015 which included the Adult Parole Board treating the expiration of a non-parole period as a target date only and taking into account all relevant material before parole is granted.
"It has meant that so many people are denied parole, including disproportionately Aboriginal and Torres Strait Islander women who don't have access to appropriate housing," Ms Shwartz said on Monday.
"A lot of people are denied parole because there's not enough time on their sentence, meaning their parole applications have been delayed, and they are instead remaining in custody.
"It is very welcome and we hope that Victoria looks at reviewing its parole process."
Ms Calgaret's mother remembers her as someone who was always looking after everyone.
"She was the rock of our family. We always knew we could rely on her when we needed help," Jenny Calgaret said.
Her mother said she had set up her house specifically so Ms Calgaret could stay there when they got parole.
"I would have looked after Heather. The whole family would have supported her," she said.
"There's no way she would have died if she was living with us."
At least 560 Aboriginal and Torres Strait Islander people have died in custody since the Royal Commission into Aboriginal Deaths in Custody - equating to one death every three weeks.
"The family hope this examination of Ms Calgaret's passing will mean that fewer Aboriginal and Torres Strait Islander people die in custody, and this will prevent other people from dying in custody," Ms Schwartz said.
The inquest into Ms Calgaret's death will begin on April 29 and will run for about 15 days.
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