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Warning to Aboriginal and Torres Strait Islander readers: This story contains images and references to a deceased person.

A doctor referred to Australia’s medical watchdog over the prison death of Aboriginal woman Veronica Nelson is appealing against adverse findings made by a coroner who ruled the medical practitioner provided substandard care in the hours before the woman died.

Coroner Simon McGregor in January found Dr Sean Runacres incorrectly assessed Nelson’s weight and failed to examine the 37-year-old when she arrived at women’s prison Dame Phyllis Frost Centre on New Year’s Eve 2019.

Dr Sean Runacres outside the Coroners Court of Victoria in May 2021.Credit: Darrian Traynor

McGregor made numerous findings against Runacres and nursing staff who were present as an unwell Nelson repeatedly asked for assistance. Nelson died at the facility days later, having used the intercom system 49 times to call for help.

In documents filed with the Supreme Court, Runacres claims McGregor’s findings were based on “inexact proofs, indefinite testimony” and indirect inferences.

The court documents claim McGregor made six errors and misapplied legal principles in establishing that Runacres acted improperly.

“[Runacres] was not made aware of Veronica Nelson’s deterioration subsequent to her reception medical assessment and had no opportunity to provide further care in light of the change in her presentation,” the legal documents say.

The medical practitioner, who currently works in aviation medicine, is asking the Supreme Court to overturn the coroner’s ruling, which found Runacres failed to physically examine Nelson and recorded her weight inaccurately.

That, the coroner found, set in motion a fatal “chain of events”.

In the days before Nelson’s death, she was arrested in Spencer Street and taken to a nearby police station for questioning on suspicion of shoplifting, on December 30, 2019.

Veronica Nelson (left) in the Dame Phyllis Frost Centre on December 31, 2019.

After being refused bail, she was transferred to the prison, where she made repeated calls for help over the intercom while heroin withdrawal and an undiagnosed medical condition ravaged her body.

She was found dead in her cell on January 2, 2020. Ambulance paramedics believed she had been dead for some time.

An autopsy later found Nelson had the undiagnosed medical condition Wilkie’s syndrome, a rare but potentially life-threatening gastrointestinal condition.

The inquest into Nelson’s death heard she was sent for a medical assessment with Runacres and registered nurse Stephanie Hills – who were both employed by private contact company Correct Care Australasia – when the woman arrived at the prison on December 31, 2019.

Veronica Nelson died in custody at the Dame Phyllis Frost Centre in January 2020.

There, Nelson’s assessment was completed within 13 minutes, and she was put in a holding cell, where she continued vomiting.

Runacres then left the prison at 5.44pm, 16 minutes before the end of his shift.

Hills told the coroner she believed Nelson was too unwell for the mainstream prison, and overrode the doctor’s decision and kept Nelson in the medical unit overnight.

Runacres told the coroner he was unable to recall the assessment or how Nelson presented, but accepted he failed to take accurate notes throughout.

Dr Sean Runacres in a CCTV image following Veronica Nelson through a corridor at the prison.

A lawyer for Runacres submitted to the inquest that the coroner should have had doubts about Hills’ credibility because there was a strained relationship between the pair at the time of Nelson’s intake.

But McGregor ultimately agreed with parts of Hill’s evidence and concluded that no physical examination was conducted during the assessment.

In handing down his findings in January, McGregor acknowledged that any rulings made about the doctor’s assessment, care and treatment of Nelson had the potential to have an impact on his professional reputation and livelihood.

McGregor also found Runacres’ notes on Nelson contained inaccuracies, including that he wrongly noted the ill woman was 40 kilograms when she weighed 33 kilograms when she died, and that the doctor failed to provide a plan for her ongoing management or ensure she was transferred to hospital.

Veronica Nelson’s mother, Aunty Donna Nelson (right), with Veronica’s partner, Percy Lovett, and family and friends.Credit: Joe Armao

These, the coroner said, were “significant departures” from the reasonable standards of care and diligence expected in medical practice.

“Dr Runacres was the health professional responsible for identifying at reception whether Veronica was fit to be held in an unobserved cell,” McGregor said in his findings.

“Dr Runacres’ failure to properly utilise this opportunity set in motion a chain of events in which [Nelson’s] medical treatment and care was inadequate in an ongoing way.”

McGregor ultimately found Nelson’s death was preventable and that the failure of prison and health staff to transfer her to hospital causally contributed to her death.

Following his findings, McGregor ordered those parts relevant to Runacres be sent to the Australian Health Practitioner Regulation Agency (AHPRA) for its consideration.

A spokeswoman for AHPRA said the agency was still considering the matter.

Correct Care Australasia was referred to the Director of Public Prosecutions for investigation.

Images contained in this story were released to the media with permission from the family. For crisis support run by Aboriginal and Torres Strait Islander people, contact 13YARN (13 92 76).

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