Australian Human Rights Commission Current issues and good practices in prison management, 16 November 2023 27. The Commission also acknowledges the observation of the Yoorook Justice Report (Victoria), that ‘First Peoples are dying at higher rates in custody not because they are more likely to die once they are in custody, but because of the staggering rates at which governments are arresting and jailing Aboriginal people’.43 28. Moreover, the Commission remains significantly concerned at what the Yoorook Justice Report (Victoria) has described as ‘failures to implement recommendations made over many years and by many inquiries’.44 As exemplified in a recent review of the Western Australian Inspector of Custodial Services into the implementation of Coronial recommendations: it was hard not to form the view that in several cases the focus was more about closing the outstanding recommendation rather than implementing sustained change in a way that met the spirit and intent of the recommendation.45 29. In January 2023, the Victorian Coroner released its findings into the Inquest into the death of Veronica Nelson, an Aboriginal woman held in custody at the Dame Phyllis Frost Centre, Victoria. The coroner commented that, ‘had the RCADIC recommendations been successfully implemented by the Government and its agencies, Veronica’s passing would have been prevented’.46 The Coroner also noted that, to date, the implementation of the RCADIC recommendations has ‘achieved too much policy, and not enough change’.47 30. The Victorian Government has announced legislative and policy changes in response to recommendations made by the Victorian Coroner including: • The decision to cease out-sourcing medical services for female prisoners to private health-care providers48 – although the Commission notes that the Victorian Government has not decided to mirror this change in the men’s prison system. • Legislative reform to loosen requirements for bail in Victoria – although civil society groups have criticised these changes as failing to meet minimum human rights standards under the Victorian Charter.49 31. In July 2023, the Western Australian Coroner released its findings into the Inquest into the death of Stanly John Inman, an Aboriginal man held in custody at the Acacia Prison, Western Australia. The coroner commented that ‘the overall quality of Mr Inman’s supervision, treatment and care was of a lower standard than it should have been because his level of risk was not properly understood’,50 and that, ‘had … culturally safe care … been available at Acacia, Mr Inman’s life journey may well have been different’. 51 8