Victorian Premier Daniel Andrews has flagged changes to the state's justice system in the wake of Veronica Nelson's death in a Melbourne prison, saying the tragedy would "drive reform".
Veronica Nelson's family has given permission for the use of her name and image.
Mr Andrews made the comments a day after a coroner found the death of the 37-year-old Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman in custody was preventable and described her treatment in prison as "cruel and degrading", while calling for urgent reform of the state's bail laws.
Coroner Simon McGregor made 39 recommendations based on an inquest into Veronica's death, but honed in on stricter bail laws introduced in 2018, which he said were having a "discriminatory impact" on First Nations people, especially Aboriginal and Torres Strait Islander women.
Mr Andrews described Veronica's death as a "terribly tragedy".
"Her experience and the terrible way in which she was let down and failed will drive reform and change, be in no doubt about that," he said.
"We'll have more to say about those reforms quite soon and they will involve not just bail, and a better recognition in our bail laws of the clear difference between violent offending and non-violent offending, but they will also involve other matters that go well beyond the law.
"They go to issues of prisoner welfare and making sure that vulnerable Victorians — whether that be because they are First Nations Victorians, or for many other reasons — are given the support and care that they are entitled to as a basic human right."
Mr Andrews also criticised a Justice Department review done in the wake of Veronica's death that described her treatment in custody as "appropriate".
In his findings, the coroner described the review as "grossly inadequate and misleading".
The premier said it was "completely unacceptable" that internal processes to examine Veronica's death did not raise any alarms or at least "questions to answer".
"Obviously something has gone wrong here and that ought to have been obvious at a very early point," he said.
"Clearly it's not acceptable ... to have within any part of government a process that gives something 'Oh that's all fine, there's nothing to see here', only to then find ourselves where we are now."
Mr Andrews said it was "pleasing to see" that a bipartisan approach could be taken in making legal reforms, after public comments from the opposition.
"With goodwill and a partnership across the parliament then I think we can take this terrible tragedy, and whilst we can't change it, we can learn from it and honour Veronica Nelson's memory by making sure that this sort of tragedy does not happen again," he said.
The premier said he didn't want to name a "hard deadline" but said it was likely changes would take place within months.
"Certainly in the first half of this year I want to be able stand with the Attorney[-General] ... and be able to answer all of your questions about this law reform," he said.
Opposition calls for urgent action
Victorian Liberal leader John Pesutto described the coroner's findings as "harrowing reading".
"Just one long catastrophic litany of failings, from the laws themselves to not heeding the calls for help that Veronica was making in her final days and her final hours," he told ABC Radio Melbourne.
Mr Pesutto called for an urgent response to the coroner's recommendations, but warned against an "extended period of review".
"If I was premier today, I'd already be [in] meeting with key stakeholders in the justice system to say there are things we can do immediately," he said.
He said the opposition was open to potentially repealing changes to bail laws which were made in 2018.
Those changes were made as a result of the 2017 Bourke Street attack, in which James Gargasoulas murdered seven people while out on bail.
"The whole idea was to toughen up some of the [bail] laws around violent offending," Mr Pesutto said.
"In no universe is what Veronica did anything remotely resembling the sorts of things that the laws which were changed in 2018 were intended to address."
Karen Fletcher, the executive officer at Flat Out, a community support organisation for women leaving prison, said the volume of women going in and out of custody was a "disaster".
She said there had typically been no shortage of funding to expand prisons or police forces yet her organisation had just two case workers amid an "explosion" in prison numbers.
"There are so many women caught up in prison … 100 a month going in, coming out. Most of them spending less than a month there, most of them on remand," Ms Fletcher said.
"They're losing their homes, they're losing their jobs, they're losing their connections to community."
Ms Fletcher called for the culture of prison institutions to be examined.
"We're relying on a system that's about punishment and restraint to deal with a problem that's about health," she said.
She said the government needed to urgently look at areas that have an impact on social issues such as health, education and housing, in order to make a true difference.
"Those things that keep people out of the criminal legal system and actually have an impact on the social problems — and not just a punishing approach," she said.
