Aboriginal deaths in custody in Victoria: where Yoorrook and the Royal Commission’s recommendations stand
Our newsroom acknowledges the Traditional Owners of the lands across Victoria on which our reporting takes place. We pay respect to Elders past and present, and we recognise the deep ongoing impact that the deaths in custody of Aboriginal and Torres Strait Islander people have on families, communities and Country. This piece discusses the death of an Aboriginal woman in custody and references coronial findings; readers may find it distressing.
Three and a half decades after the Royal Commission into Aboriginal Deaths in Custody handed down its final report in 1991, the structural questions it raised have not been resolved in Victoria. The Yoorrook Justice Commission has reported. The Coroners Court has handed down findings. The Implementation Monitor has published its assessments. Where the gap sits in 2026 is between recommendations made and recommendations carried into practice — and that is the gap our team has been mapping.
What the foundational documents say
The 1991 Royal Commission produced 339 recommendations addressing custody, the underlying causes of over-imprisonment and self-determination. Its core finding was that Aboriginal and Torres Strait Islander people were not dying at higher rates per capita inside custody than non-Indigenous people — but that they were vastly over-represented in custody in the first place, which is what produced the disproportionate death toll.
The Yoorrook Justice Commission, established in 2021 as Australia’s first formal truth-telling body, delivered its Yoorrook for Justice report in September 2023. The report contained 46 recommendations addressing Victoria’s child protection and criminal justice systems. The Victorian Government responded in April 2024, accepting four recommendations in full, 24 in principle and noting 15 as still under consideration. Three were rejected, including raising the minimum age of criminal responsibility to 14 without exceptions and prohibiting the detention of children under 16.
The Coroners Court of Victoria’s findings into the death of Veronica Nelson — a Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman who died at the Dame Phyllis Frost Centre on 2 January 2020 after being remanded in custody — were handed down in January 2023. The findings were extensive and unsparing. The Coroner found her death was preventable, found systemic failings in healthcare provision and called for substantial reform of Victoria’s bail laws.
The Veronica Nelson follow-through
The post-Veronica Nelson bail reforms passed Parliament in 2023, removing the “reverse-onus” structure that had produced rising remand numbers for Aboriginal women. The implementation review in 2024 and 2025 reported a measurable drop in the female Aboriginal remand population, although the male equivalent did not move at the same pace.
The 2025 bail-laws amendments — which tightened the framework for some property and youth offences in response to a different political conversation — drew strong public concern from the First Peoples’ Assembly of Victoria and from Veronica Nelson’s mother Aunty Donna Nelson, who said the changes risked repeating the mistakes that led to her daughter’s death. Our newsroom has reported on those concerns directly. Where the 2025 amendments interact with the post-Veronica Nelson reforms is one of the policy questions Yoorrook has continued to examine through 2026.
Where the data sits in 2026
Aboriginal and Torres Strait Islander people remain over-represented in Victorian custody at a rate that has not improved meaningfully across the past five years. The Implementation Monitor’s reports have catalogued the slow movement against Yoorrook’s targets. The headline numbers our newsroom uses:
- Aboriginal adults are imprisoned at a rate many multiples that of non-Indigenous adults.
- Aboriginal children are detained at rates significantly higher than non-Indigenous children, even with the reforms passed since 2018.
- The number of Aboriginal deaths in custody nationally has continued to rise since 1991, with more than 600 deaths recorded across all jurisdictions since the Royal Commission.
These are state and national patterns. The trajectory of any individual reform is harder to read on a single year, which is why the Implementation Monitor’s work matters. Our team treats the Monitor’s published assessments as the most authoritative running ledger.
Healthcare in custody
The Coroner’s findings in the Veronica Nelson matter were particularly direct on the question of in-custody healthcare. The report identified failures in clinical assessment, in the response to her deteriorating condition and in the cultural competence of the staff she encountered.
The reform program that followed has included changes to the Justice Health framework, new clinical pathways for women with substance dependence in remand, and expanded access to Aboriginal Community Controlled Health Organisations as the providers of choice. The implementation has been uneven across the prison system, with the Dame Phyllis Frost Centre receiving more attention than several of the regional and male-dominated facilities.
The self-determination thread
Yoorrook’s recommendations are organised around a central principle: that Aboriginal-led decision-making over Aboriginal lives is the structural lever that has been missing from previous reform attempts. The First Peoples’ Assembly, which has been negotiating the Treaty framework with the Victorian Government, holds the formal seat at the policy table for that work.
The justice-specific applications include:
- Aboriginal Community-Controlled Organisations as the preferred deliverers of diversion, healing and support programs.
- Greater funding stability for the Victorian Aboriginal Legal Service, which has been carrying a heavy caseload across criminal, child protection and coronial matters.
- The expansion of the Koori Court — which now sits at multiple Magistrates’ Court locations and provides a culturally safe sentencing process — into more areas of the system.
- Improved training for non-Indigenous justice workers, including police, corrections and youth justice staff, on cultural safety and on the structural drivers of over-imprisonment.
What is in front of Parliament now
The 2026 legislative program includes several pieces of work that bear on this topic. The bail-laws monitoring framework, the youth-justice reform package and the Treaty-related machinery legislation are the three our newsroom is following most closely. The First Peoples’ Assembly publishes its own running commentary on those processes, and our team treats that commentary as the primary source for the Aboriginal-led perspective on what is and isn’t moving.
Mindframe and Indigenous reporting
This is sensitive material. We follow the Mindframe guidelines on reporting deaths and the Indigenous-specific reporting guidance from the Australian Press Council and the Walkley Foundation. We do not republish details of the manner of death where they are not material to the public-interest question, and we use the names of deceased Aboriginal and Torres Strait Islander people only where there is published consent from the family.
The Nelson family has spoken extensively in public, including through the formal advocacy of Aunty Donna Nelson, and has consistently asked that Veronica’s name continue to be used in reform conversations. Our newsroom uses her name with that history in mind.
Where to look for the official material
The Yoorrook Justice Commission’s reports, the Implementation Monitor’s published assessments, the First Peoples’ Assembly of Victoria’s policy positions, and the Coroners Court of Victoria’s findings in the Nelson matter are all on the public record and are linked from those bodies’ official websites. The Australian Institute of Criminology publishes the national Deaths in Custody Monitoring Program annual report, which provides comparable data across all jurisdictions.
Support contacts
13YARN is a 24/7 crisis support line for Aboriginal and Torres Strait Islander people on 13 92 76. Lifeline is on 13 11 14. The Victorian Aboriginal Legal Service is on 1800 064 865. If you are in custody or worried about someone in custody, the Aboriginal Community Justice Panels operate across many parts of Victoria and can be contacted through the Victorian Aboriginal Community Services Association or local Aboriginal Co-operatives. For families navigating the coronial process, the Coroners Court of Victoria’s Koori Engagement Unit provides culturally safe support.
Tom Whitford reports on regional and rural Victoria for Victoria Crime News.
