Inquest Reveals Preventable Death of Aboriginal Woman in Custody
An Aboriginal woman, Heather Calgaret, tragically died in custody at the age of 30, with an inquest finding her death entirely preventable. Calgaret had experienced serious health declines following the removal of her newborn daughter upon birth—a traumatic event labelled as "hell" by her. Coroner Sarah Gebert, delivering a comprehensive 300-page report, highlighted the deteriorating effects on Calgaret’s mental and physical wellbeing after her baby was taken away, exacerbating her existing issues.
Calgaret, a proud Yamatji, Noongar, Wongi, and Pitjantjatjara woman, was pregnant when she entered Dame Phyllis Frost Women’s Prison in July 2019. The enforced separation from her children led to depression, shame, and obesity, alongside a diabetes diagnosis during her incarceration. Prior to her death, Calgaret sought parole, expressing frustration over barriers posed by programme requirements that were unavailable to her. Despite being eligible for parole months after her sentencing, delays and a lack of appropriate accommodation led to a continual denial of her release.
Just weeks before her death, Calgaret was prescribed a high dose of Suboxone—an opioid replacement therapy—that was deemed too potent for her tolerance. This prescription was considered inappropriate by the coroner, who pointed out that there was insufficient escalation of care until the following morning when Calgaret’s health dramatically declined.
On November 23, 2021, Calgaret was found unconscious by her sister, Suzzane. Despite immediate medical attention, she succumbed to her condition four days later. Outside the court, Suzzane expressed the profound tragedy of her sister’s death and called for urgent reforms within the prison system to prevent similar incidents.
The coroner has since recommended implementing community-based Aboriginal health care within the women’s prison, along with additional support for women giving birth while incarcerated. In particular, it was suggested that psychological care be provided for those whose children are removed. Gebert also identified significant flaws in the parole application process, noting a lack of transparency and the disproportionate impact on Aboriginal women regarding available treatment options.
The recommendations aim to prevent another loss and address broader systemic issues affecting Aboriginal and Torres Strait Islander communities within the justice system. For those seeking support, resources like Lifeline and 13YARN are available to provide assistance.