A coroner’s report has revealed that the death of Aboriginal woman Heather Calgaret while in custody was preventable. The findings, delivered by Victorian coroner Sarah Gebert, outline multiple missed opportunities for intervention that could have saved the 30-year-old mother of four. Calgaret died on November 22, 2021, following inappropriate medical treatment after suffering from severe mental health issues during her incarceration.
Calgaret entered Dame Phyllis Frost Women’s Prison in July 2019, six months pregnant. Upon giving birth, her newborn baby was taken from her, a traumatic event exacerbated by her prior experiences of having her other children removed due to the impacts of the Stolen Generations. The coroner emphasized that this moment was pivotal in Calgaret’s mental decline, stating, “Each of these factors would be expected to produce a range of both trauma-related symptoms and feelings of despair.”
Despite being eligible for parole over a year before her death, Calgaret’s requests for mental health support went unaddressed. She wrote a letter pleading for release, citing a lack of access to necessary rehabilitation programs within the prison. “I have four children that need me. I believe I have suffered enough,” she implored. Unfortunately, her letter was never forwarded to the parole board.
In the final months of her life, Calgaret was prescribed a dosage of opiate replacement therapy that was too high for her tolerance. Her sister, Suzzane Calgaret, who was incarcerated with her, discovered her struggling to breathe the following morning. A “code black” was called, but Calgaret succumbed to her condition four days later in the hospital.
The coroner’s findings indicated that if Calgaret had not been given the opioid or had received proper supervision afterward, she would likely still be alive. There was a notable lack of careful consideration in the medical decisions made regarding her treatment.
Outside the courtroom, Suzzane Calgaret expressed profound grief and frustration at the systemic failures that led to her sister’s death. “There’s a reason now for her passing and that reason has been justified by the outcome, but it doesn’t bring her back,” she said.
In response to the findings, coroner Sarah Gebert issued 16 recommendations aimed at improving the care of women in custody. These included provisions for monitoring the mental health of women who give birth while incarcerated and enhancing psychological services within the prison system. Gebert also called for a review of the parole application process to ensure it aligns with the principles of justice and rehabilitation.
The case highlights critical issues within the Australian prison system, particularly regarding the treatment of Indigenous women. As advocates push for reforms, the hope remains that the lessons learned from Calgaret’s tragic death will lead to meaningful changes in the future.
