In the hours before her death on the floor of a flooded prison cell, Veronica Nelson repeatedly called for help.
Other prisoners, disturbed by her screaming, also called prison guards to help her.
Veronica was being treated with painkillers, anti-nausea medication and other prescription pills while withdrawing from heroin.
After two days in a medical ward of Melbourne's Dame Phyllis Frost Centre she was moved to a regular cell and experienced painful leg cramps and frequent vomiting.
She made multiple requests before she was given cordial and socks to help with cramping. Guards told her they couldn't help because they didn't have keys.
A sign on her cell said "do not unlock".
At 3.56am on January 2, 2020 Veronica made her second last call to a guard. Her screaming was loud in the recording, played to the Victorian Coroners Court on Tuesday.
"You need to try and stop because you're keeping the other prisoners awake. I can't give you anything else," a guard told her.
Two minutes later she made her final call. She was given the option to go to the medical ward but said she wanted to stay where she was.
Three hours later Veronica's body was discovered in cell 40 when she didn't respond to the morning headcount. A nurse believed she had been dead for some time.
An autopsy found Veronica, who weighed just 33kg and had a BMI of 13, had a grossly dilated and distended stomach.
She died from complications of Wilkie's syndrome, in a setting of withdrawal from chronic opiate use. The rare syndrome is characterised by nausea and vomiting, which can lead to fatal electrolyte imbalances.
"(Veronica) may have passed of natural causes but if it could have been avoided, it should have been. If her pain could have been alleviated it should have been," counsel assisting the coroner, Sharon Lacy said.
"She was detained and in state care. She was entitled to be treated with dignity, in life and in passing."
More than 60 witnesses are expected to be called at the month-long inquest into her death, examining the adequacy of prison healthcare, the impact of her Aboriginality and Victorian bail laws.
Veronica was arrested in Melbourne on December 30, 2019 on shoplifting and bail offences. She represented herself in a bail application but it was denied after prosecutors argued her history showed she didn't take bail seriously.
Her family hope the inquest will prevent future deaths in custody.
"This inquest is first and foremost about Veronica, and how a broken criminal justice system locked my daughter up and let her die while she begged for help, over and over," Aunty Donna Nelson said.
"We are still connected and her spirit won't rest until those who are responsible for Veronica's death are exposed and held to account. Only then will my Poccum be free."
Percy Lovett, her partner of 20 years, described her as a strong and helpful woman, who was his other half and taught him about Indigenous culture.
"Whenever she would talk about Blackfellas, the stories she would come out with were unreal," he said.
"She knew a hell of a lot more than me. She really woke me up and made me listen."
Veronica's nephews danced at a smoking ceremony at the court on Tuesday morning.
