A nurse has told a coronial inquest she suggested sending Veronica Nelson to hospital the day she arrived at prison, but was overruled by a doctor who said the 37-year-old looked "generally well", two days before she died alone in a cell.
The family of Veronica Nelson have granted permission to use her image and requested she be referred to as Veronica on second reference.
Veronica was found dead at Dame Phyllis Frost Centre in Melbourne's west in the early hours of January 2, 2020, after making multiple intercom calls for help.
An autopsy found she died from complications caused by a rare medical condition affecting the intestine and heroin withdrawal.
On Monday, registered nurse Stephanie Hills told the inquest she was "alarmed" by the Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman's appearance when she arrived at the prison on remand on New Year's Eve in 2019.
Ms Hills broke into tears before telling the coroner she had to physically support Veronica as she took her blood pressure during her first health assessment because Veronica was unable to support herself in the chair.
The registered nurse said after observing Veronica's low heart rate and blood pressure she told the doctor, Sean Runacres, who was running the examination, it was her opinion that the unwell woman should be sent to hospital.
"I expressed my concern and stated that, 'do you think we need to send her to hospital'," Ms Hills said.
She said he responded by saying "I'm the doctor, I will make the decisions".
"And I believe there was a 'you're just a nurse' thrown in there as well," Ms Hills said.
She said due to the medical hierarchy there was "no way" a nurse with a doctor before them could override that decision and call an ambulance from the examination room.
“I did have concerns but at the end of the day it’s the doctor's decision, what they do and don’t do," Ms Hills said.
The nurse told coroner Simon McGregor that some of the observations recorded by Dr Runacres in the health check were not actually gathered during the examination she witnessed.
She said that was partly because it was not possible to get Veronica onto the scales to be weighed or onto an examination bed for a proper abdominal assessment.
The court heard the examination lasted around 13 minutes, which was 15 to 30 minutes less than what it would normally take for an assessment of that kind.
Ms Hills said she felt at the time the health assessment was not adequate and a proper test of Veronica's conscious state was not done to justify the normal Glasgow Coma Scale score noted on the health paperwork.
"He [Dr Runacres] didn't move from his chair and he didn't examine her pupils either to see if they were dilated, reaction, anything," Ms Hills said.
She said Veronica was "frequently incoherent", struggled to understand the health paperwork she was signing and repeatedly told the healthcare workers "I feel sick, I have pain".
In his notes Dr Runacres noted that Veronica "looked generally well", was "alert but not drowsy" and "not toxic looking".
Ms Hills told the court she "absolutely" disagreed that Veronica appeared well.
"She was not alert, she was drowsy, she was slumped over the side of the chair as I've already stated, I have no idea what 'not toxic looking' is, I have never, ever read that in a medical file," she said.
Dr Runacres, who was due to finish work when Veronica was examined, prescribed her with what is known as a rapid withdrawal pack — containing opioids, anti-nausea medication and paracetamol.
Ms Hills said after Dr Runacres had left, she overruled his decision to clear Veronica and send her from the medical unit to the general part of the prison.
Instead, she organised for her to stay in the medical unit overnight for closer observation.
She said she did so after consulting a psychiatric nurse whose note from Veronica's first day in the prison recommended she stay in the medical unit "due to severe heroin withdrawal symptoms".
In her submission to the inquest, Ms Hills said she "deeply regret[ted]" not calling an ambulance and organising for Veronica to be sent to hospital that night.
Dr Runacres is expected to give evidence to the coroner later this week.
Veteran prison officer had never seen someone as 'thin and frail' as Veronica
Earlier, the inquest heard a senior prison officer was "quite shocked" at the appearance of Veronica when she arrived at Dame Phyllis Frost Centre.
Christine Fenech told the inquest she had never seen anyone look as "thin and frail" as Veronica did when she arrived on December 31, 2019.
Ms Fenech said she spoke to her supervisor to share her concerns about Veronica's health, but as she was not a medical expert it was not her role to send her to hospital.
She also said Veronica appeared to "perk up" at times and was able to wheel a trolley of her belongings down to a cell in the main part of the prison after she left the medical unit on January 1.
Ms Fenech also explained to the inquest that when the prison was in lockdown overnight, guards would need a security advisor to come across and unlock the cells.
The inquest heard that that meant that in the middle of the night if someone needed a drink other than through their cell tap if they had a cup, there was no way to provide that drink without getting the supervisor.
At the start of the hearings the inquest heard several distressing intercom calls Veronica made in the two days before she died, requesting cordial and something to drink as repeated vomiting left her badly dehydrated.
On several occasions she was told it was not possible because there were not enough officers on duty.
The inquest also heard a pink sign on Veronica's door that read "new reception: do not unlock" was routinely put on the door for new arrivals in the main Yarra Unit if they had not yet had a briefing on the rules.
"Just so they can have their initial interview with the staff members in the morning to run through all the orientation rules and regulations of the unit," Ms Fenech said.
Ms Fenech, who was not working in the Yarra Unit where Veronica died, told the inquest she would "always" go down to a cell if a prisoner used the intercom to call for help, so she could see them "face to face" and make a better judgement on their welfare.
