In the hours before her death on the floor of a flooded prison cell, Veronica Nelson repeatedly called for help.
Disturbed by her screams other prisoners called too.
Veronica was being treated with painkillers, anti-nausea medications and other prescription drugs while withdrawing from heroin in a cell at Melbourne's women's prison, the Dame Phyllis Frost Centre.
She was arrested on December 30, 2020 on warrants for breaching bail and suspicion of shoplifting, and interviewed by police without a lawyer present.
The magistrate who issued the warrant noted she could be released to appear in court at Shepparton.
But an inquest which began on Tuesday heard that because Melbourne Magistrates Court was open officers decided she'd be held in custody to appear there.
Veronica represented herself in a bail application but it was denied and she was transferred to prison.
On arrival she needed to be physically supported and was incoherent. A nurse, alarmed by her low blood pressure and heart rate, told a doctor she needed to be sent to hospital, the inquest heard.
Instead, after two days on a medical ward, she was transferred to a regular cell.
Veronica was still vomiting and could be heard crying in pain from leg cramps in recordings played in the Victorian Coroners Court on Tuesday.
She asked four times to see a doctor before a guard said "it's not an emergency, stop asking".
Other guards said they couldn't give her the drinks she asked for because they didn't have keys.
A sign on her cell said "do not unlock".
At 3.56am on January 2, 2020 Veronica made her second last call for help, screaming loudly.
"You need to try and stop because you're keeping the other prisoners awake. I can't give you anything else," a guard told her.
Two minutes later she made her final call. She was given the option to go to the medical ward but said she wanted to stay where she was.
Then there was silence. Veronica's body was discovered three hour later when she didn't respond to the morning head count.
An autopsy found Veronica, who weighed 33kg and had a BMI of 13, had a grossly dilated and distended stomach.
She died from complications of Wilkie's syndrome, in a setting of withdrawal from chronic opiate use. The rare syndrome is characterised by nausea and vomiting, which can lead to fatal electrolyte imbalances.
"(Veronica) may have passed of natural causes but if it could have been avoided, it should have been. If her pain could have been alleviated it should have been," counsel assisting the coroner, Sharon Lacy said.
"She was detained and in state care. She was entitled to be treated with dignity, in life and in passing."
More than 60 witnesses are expected to be called in a five-week inquest, examining the adequacy of prison healthcare, the impact of her Aboriginality and Victorian bail laws.
Her mother, Aunty Donna Nelson, said she had Veronica when she was 16 and as the eldest of her children, Veronica took on a mothering role when she battled with postnatal depression.
"This inquest is first and foremost about Veronica, and how a broken criminal justice system locked my daughter up and let her die while she begged for help, over and over," she said.
"We are still connected and her spirit won't rest until those who are responsible for Veronica's death are exposed and held to account. Only then will my Poccum be free."
Percy Lovett, her partner of 20 years, said she was his other half, a brainy woman who taught him about Indigenous culture.
"She knew a hell of a lot more than me. She really woke me up and made me listen," she said.
Veronica's nephews danced at a smoking ceremony at the court on Tuesday morning.