WARNING: Aboriginal and Torres Strait Islander readers are warned the following article contains an image of a deceased person.

An Aboriginal woman’s newborn had been taken from her, she was denied parole and then a doctor prescribed her a high dose of synthetic opiates leading to her death.

Heather Calgaret’s death in custody was preventable and her health in prison had deteriorated from the moment her baby was removed from her at birth, a coroner found on Monday.

“Not only was her passing preventable, she should never have passed in the manner that she did,” Victorian coroner Sarah Gebert said as she delivered a 300-page finding following an inquest.

The proud Yamatji, Noongar, Wongi and Pitjantjatjara woman, 30, had been six months’ pregnant when she arrived at Dame Phyllis Frost women’s prison in July 2019.

The removal of her daughter – which Calgaret had described as “hell” – was a “pivotal moment” in her overall health decline while in custody, Gebert found.

She experienced depression, grief, shame and trauma from the child’s removal and separation from her three other children, became obese and was diagnosed with diabetes over her next two years in prison.

Calgaret pleaded to be released on parole about six months before her death, writing a letter expressing frustration as one of her parole conditions was to complete a program that was not available.

“I have been told I need to complete the See Change program to complete parole, Dame Phyllis Frost is not running it,” she wrote, as she asked to be permitted to complete the program outside prison.

“I have four children that need me, I believe I have suffered enough.

“The prison system is holding me back from getting parole … someone please read and answer my letter.”

But her letter was never forwarded to the parole board.

She had been eligible to be considered for parole seven months after beginning her sentence, but this did not occur until much later and she was denied due to a lack of suitable accommodation.

Calgaret had 10 weeks left to serve of her two-year and four-month jail term for armed robbery when she died, after a doctor prescribed her a dosage of opiate replacement therapy that was too high for her tolerance level.

“The dose given was too high, there was no escalation to her care until the following morning,” Gebert said.

“Heather’s death could have been prevented.”

A doctor’s prescription of Suboxone – a buprenorphine used to treat opioid dependence – the day before she was found unconscious was “inappropriate and lacked careful consideration”, she said.

Calgaret’s sister Suzzane, who was housed with her at the prison, found her struggling to breathe on the morning of November 23, 2021.

She shook Calgaret to let her know it was time for the daily count, but her younger sister was not moving.

A “code black” was called and she was taken to hospital where she died four days later.

Outside court, Suzzane welcomed the findings but said it should not have taken her sister’s death for changes to be made to the prison system.

“I hope they just have learned from this because it’s taken my sister’s life, my mum’s daughter’s life,” she said.

“There’s a reason now for her passing, and that reason has been justified by the outcome, but it doesn’t bring her back.”

Gebert issued several recommendations, including that the justice system implement community-based Aboriginal health care inside the women’s prison.

She said women who give birth in custody should be given additional care, including psychological treatment if their babies are removed from them.

She also found “numerous issues” with the parole application process, including a lack of transparency in the prison and that Aboriginal people were disproportionately impacted by lack of available treatment.

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