The Victorian Legal Services Commissioner has launched a complaint and investigation into a barrister tasked with assisting Veronica Nelson, who died alone in her prison cell.
Commissioner and head of the Victorian Legal Services Board Fiona McLeay initiated the complaint and investigation after Coroner Simon McGregor found Ms Nelson's death was preventable.
He also found that legal services provided to Ms Nelson by Melbourne barrister Tass Antos were inadequate.
"As the regulator of the legal profession in Victoria, we believe everyone who exercises their basic right to have legal representation should also receive an appropriate standard of legal service," Ms McLeay said in a statement.
"I have initiated a complaint and investigation of my own motion into the conduct of lawyer Tass Antos, following the finding by Coroner McGregor that the legal services he provided to Ms Nelson were inadequate."
Mr Antos was given a brief to represent Ms Nelson on December 31, 2019, and saw her for a maximum of six minutes in what the coroner described as "clearly insufficient for him to obtain instructions and provide advice appropriate to her circumstances".
Ms Nelson ultimately made her own bail application, which was refused.
Mr Antos couldn't recall details of meeting Ms Nelson during an inquest into her death, but in an email he called her "aggressive and dismissive" and said her bail had "unsurprisingly" been denied.
The 37-year-old Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman died alone in her cell at Dame Phyllis Frost Centre in January 2020 from complications of the gastrointestinal condition Wilkie's syndrome, in a setting of withdrawal from heroin.
The Victorian Legal Services Board also agreed with the coroner's recommendation to mandate cultural awareness training for lawyers.
The power for making such a move sat with the Law Council of Australia, so the board would raise it directly with the council, Ms McLeay said.
"In addition, we will do all we can to ensure First Nations cultural awareness training is available to lawyers in Victoria when planning their annual CPD (Continuing Professional Development) key requirement," she said.
"As this develops, we strongly encourage lawyers to reflect on and build their understanding of First Nations People's culture and needs, particularly if working with them directly."
The board continued to work with legal sector stakeholders to improve cultural awareness among lawyers, Ms McLeay said.
Mr Antos has been contacted for comment.