Aboriginal and Torres Strait Islander readers are advised that this article contains images and names of people who have died.
On 28 July 2025, almost four years since the tragic passing of Heather Calgaret, Coroner Sarah Gebert delivered the findings and recommendations from the coronial inquest into Heather’s passing. The Coroner found that not only was Heather’s passing preventable but she should not have passed away in the manner that she did.
Heather Calgaret was a proud Yamatji, Noongar, Wongi and Pitjantjatjara woman. She was born in Dandenong and was the middle child of her large family. She was also a mother to four beautiful children, who she loved dearly and desperately wanted to be reunited with. She was very proud of her culture and enjoyed painting and writing. Heather was the rock of her family, always helping and caring for everyone.
Heather died in custody in November 2021 after being administered a high dose of buprenorphine despite not having a history of opiate use. She was found in critical condition at Dame Phyllis Frost Centre (DPFC) by her sister, Suzzane, who describes Heather as her “soulmate” and “other half”. Heather was only 30 years old and was less than 10 weeks away from completing her prison sentence when she passed away.
The Coroner found that Heather should not have been prescribed such a high dose of buprenorphine and that this dose was likely to have contributed to Heather’s respiratory depression, collapse, cardiac arrest and subsequent death. The Coroner found that the administration of this high dose of buprenorphine was inappropriate and, without it, Heather would not have passed away. The Coroner also found that, if Heather had been properly observed and monitored after her buprenorphine dose, she could have been treated appropriately and her passing may have been prevented.
For the first time in Victoria since the toughening of parole laws, this coronial inquest examined Victoria’s parole application system, including delays, the availability of programs, and support for obtaining suitable accommodation. Heather had been eligible for parole for almost one year before she passed away. She was denied parole one month before she passed due to lack of suitable accommodation. The Coroner agreed with the expert opinions of Dr Amanda Porter, Dr Crystal McKinnon and Karen Fletcher, finding there were numerous issues with the way Heather’s parole application was handled, including Corrections Victoria’s lack of adherence to metrics, poor engagement with Heather, poor documentation practices, lack of cultural engagement, lack of availability of required treatment program, and insufficient support to identify suitable housing options to enable her release on parole.
On 28 July 2025, almost four years since the tragic passing of Heather Calgaret, Coroner Sarah Gebert delivered the findings and recommendations from the coronial inquest into Heather’s passing. The Coroner found that not only was Heather’s passing preventable but she should not have passed away in the manner that she did.
Heather Calgaret was a proud Yamatji, Noongar, Wongi and Pitjantjatjara woman. She was born in Dandenong and was the middle child of her large family. She was also a mother to four beautiful children, who she loved dearly and desperately wanted to be reunited with. She was very proud of her culture and enjoyed painting and writing. Heather was the rock of her family, always helping and caring for everyone.
Heather died in custody in November 2021 after being administered a high dose of buprenorphine despite not having a history of opiate use. She was found in critical condition at Dame Phyllis Frost Centre (DPFC) by her sister, Suzzane, who describes Heather as her “soulmate” and “other half”. Heather was only 30 years old and was less than 10 weeks away from completing her prison sentence when she passed away.
The Coroner found that Heather should not have been prescribed such a high dose of buprenorphine and that this dose was likely to have contributed to Heather’s respiratory depression, collapse, cardiac arrest and subsequent death. The Coroner found that the administration of this high dose of buprenorphine was inappropriate and, without it, Heather would not have passed away. The Coroner also found that, if Heather had been properly observed and monitored after her buprenorphine dose, she could have been treated appropriately and her passing may have been prevented.
For the first time in Victoria since the toughening of parole laws, this coronial inquest examined Victoria’s parole application system, including delays, the availability of programs, and support for obtaining suitable accommodation. Heather had been eligible for parole for almost one year before she passed away. She was denied parole one month before she passed due to lack of suitable accommodation. The Coroner agreed with the expert opinions of Dr Amanda Porter, Dr Crystal McKinnon and Karen Fletcher, finding there were numerous issues with the way Heather’s parole application was handled, including Corrections Victoria’s lack of adherence to metrics, poor engagement with Heather, poor documentation practices, lack of cultural engagement, lack of availability of required treatment program, and insufficient support to identify suitable housing options to enable her release on parole.
The Coroner found that Victoria’s parole system is operating in a way that may make it impossible to give effect to some court sentences and is also inconsistent with the department’s commitments to Aboriginal self-determination and reducing over-representation of Aboriginal and Torres Strait Islander people in Victorian custodial settings.
The Coroner also commented on how the removal of Heather’s youngest child, who she gave birth to in custody, was a pivotal moment in Heather’s deteriorating mental health and overall wellbeing. The Coroner found that it was a missed opportunity to support an Aboriginal woman to move forward and break the cycle of child removal. The Coroner commented on the deep trauma caused to Aboriginal women when their children are removed, which is unique trauma historically linked to colonial violence. The Coroner said Heather’s application to have her newborn child stay with her in prison was considered in a way that focused on deficits rather than strengths.
Coroner Gebert, and the expert health panel who gave evidence before the inquest, all agreed that there was a significant decline in Heather’s health while she was in prison. It was found that she did not have access to adequate culturally safe care to address this declining wellbeing, despite there being multiple opportunities for intervention. At the time that she was incarcerated, healthcare at DPFC prison was delivered by private provider CorrectCare Australasia (CCA). Heather gained over 60 kilograms while she was in prison, developed type 2 diabetes and obstructive sleep apnoea and was prescribed seven or more medications – despite not being provided with sorely needed mental health or holistic treatment. Expert witness Professor Newman commented that, in Heather’s case, medications alone were unlikely to be effective. Heather attended over 100 medical appointments throughout her time in custody. Records show Heather was only seen four times by a psychiatric nurse practitioner.
Since Heather’s passing, healthcare in DPFC is now provided by a public provider as per recommendations that came out of the passing of proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman Veronica Marie Nelson, who was also incarcerated at DPFC at the same time as Heather. However, Coroner Gebert today stressed the importance of having Aboriginal community-controlled health organisations available in prison to meet the need for culturally safe and appropriate care for women.
Suzzane Calgaret, Heather Calgaret’s sister, and Aunty Jenny, Heather Calgaret’s mother, said:
“Today doesn’t necessarily bring us peace about Heather’s passing – because we already knew what had happened to her. If anything, it has just reassured us. All we have left now are memories of Heather. We have her voice on the radio, the photos that will remind us that she was here and that she was alive.
“There’s that quote – ‘Don’t think about the memories too much because that will kill you faster.’ We have used this as sort of a defense mechanism; it’s too much for the heart. It doesn’t even matter what happens to the doctor and the nurses; they still get to walk around with their life intact.
“When I went into the room and tickled her, I knew something was wrong, I knew her spirit was already gone. That moment, I have to live with every day. Knowing that my sister didn’t turn her head or open her eyes to me.
“We thank the Coroner. She had a lot to determine in the findings and she really studied it through and through. She did have a lot of heart, and I think she really empathised with Mum through her feelings and emotions. She had a few tears.
“We’re all human at the end of the day and we need to learn to appreciate each other no matter what race, colour, shape or size.
“Life really is precious.”
The Coroner found that Victoria’s parole system is operating in a way that may make it impossible to give effect to some court sentences and is also inconsistent with the department’s commitments to Aboriginal self-determination and reducing over-representation of Aboriginal and Torres Strait Islander people in Victorian custodial settings.
The Coroner also commented on how the removal of Heather’s youngest child, who she gave birth to in custody, was a pivotal moment in Heather’s deteriorating mental health and overall wellbeing. The Coroner found that it was a missed opportunity to support an Aboriginal woman to move forward and break the cycle of child removal. The Coroner commented on the deep trauma caused to Aboriginal women when their children are removed, which is unique trauma historically linked to colonial violence. The Coroner said Heather’s application to have her newborn child stay with her in prison was considered in a way that focused on deficits rather than strengths.
Coroner Gebert, and the expert health panel who gave evidence before the inquest, all agreed that there was a significant decline in Heather’s health while she was in prison. It was found that she did not have access to adequate culturally safe care to address this declining wellbeing, despite there being multiple opportunities for intervention. At the time that she was incarcerated, healthcare at DPFC prison was delivered by private provider CorrectCare Australasia (CCA). Heather gained over 60 kilograms while she was in prison, developed type 2 diabetes and obstructive sleep apnoea and was prescribed seven or more medications – despite not being provided with sorely needed mental health or holistic treatment. Expert witness Professor Newman commented that, in Heather’s case, medications alone were unlikely to be effective. Heather attended over 100 medical appointments throughout her time in custody. Records show Heather was only seen four times by a psychiatric nurse practitioner.
Since Heather’s passing, healthcare in DPFC is now provided by a public provider as per recommendations that came out of the passing of proud Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman Veronica Marie Nelson, who was also incarcerated at DPFC at the same time as Heather. However, Coroner Gebert today stressed the importance of having Aboriginal community-controlled health organisations available in prison to meet the need for culturally safe and appropriate care for women.
Suzzane Calgaret, Heather Calgaret’s sister, and Aunty Jenny, Heather Calgaret’s mother, said:
“Today doesn’t necessarily bring us peace about Heather’s passing – because we already knew what had happened to her. If anything, it has just reassured us. All we have left now are memories of Heather. We have her voice on the radio, the photos that will remind us that she was here and that she was alive.
“There’s that quote – ‘Don’t think about the memories too much because that will kill you faster.’ We have used this as sort of a defense mechanism; it’s too much for the heart. It doesn’t even matter what happens to the doctor and the nurses; they still get to walk around with their life intact.
“When I went into the room and tickled her, I knew something was wrong, I knew her spirit was already gone. That moment, I have to live with every day. Knowing that my sister didn’t turn her head or open her eyes to me.
“We thank the Coroner. She had a lot to determine in the findings and she really studied it through and through. She did have a lot of heart, and I think she really empathised with Mum through her feelings and emotions. She had a few tears.
“We’re all human at the end of the day and we need to learn to appreciate each other no matter what race, colour, shape or size.
“Life really is precious.”
Including tough bail laws being introduced in Victoria, the South Australian Government ruling out raising the age of criminal responsibility, a new parole board president appointed in Queensland and more.
The Australian Federal election is coming up. This is about voting for the Prime Minister and other federal politicians. It will be held on 3 May 2025.
“We can’t get information about how a party or candidate’s policies must impact prisoners,” Kelly told About Time. “Prison officers also will not provide us with any information as it is seen as political.”
Prison work differs across the country.
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