A coroner has found the death of 30-year-old Victorian Aboriginal woman Heather Calgaret in custody was entirely preventable, resulting from an inappropriate prescription of the opioid substitution drug, buprenorphine.
Heather Calgaret, who passed away less than 10 weeks before she was due for release, had requested assistance to safely withdraw from opioids. However, the prison doctor did not follow clinical guidelines in administering buprenorphine, according to Coroner Sarah Gebert. This resulted in Heather’s death due to respiratory failure.
Coroner Gebert (an Aboriginal woman herself) emphasised the preventable nature of Heather’s passing, saying:
“Not only was Heather’s passing preventable, she should never have passed in the manner she did.”
The court heard Heather was accepted into the opioid substitution therapy program despite her sentence being nearly over, with clinical guidelines recommending at least three months to safely manage withdrawal.
Heather’s sister, Suzanne Calgaret, was incarcerated in the same prison at the time and has been deeply affected by her sister’s death. Suzanne told ABC she continues to struggle daily with the loss, highlighting systemic failures.
Coroner Gebert acknowledged the profound trauma suffered by Suzanne and other Aboriginal women who had witnessed Heather’s death, stating:
“They unfortunately witnessed the unspeakable which occurred in their unit: the passing of a loved one and another death in custody.”
Heather’s family have urged the prison system to increase vigilance around prescribing powerful opioids, stressing the urgent need for reform.
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