Please note: This story contains reference to someone who has died.

The death in custody of Yorta Yorta woman Aunty Tanya Day has been referred to Victoria’s Office of Public Prosecutions after Coroner Caitlin English found an “indictable offence may have been committed in connection to Ms Day’s death”.

The inquest’s findings were released on Thursday and recommended independent human rights revisions of both the Victoria Police and V/Line transport training manuals.

“Ms Day’s death was clearly preventable had she not been arrested and taken into custody,” English said as she delivered her findings via livestream due to COVID-19.

A number of other recommendations also concerned Victoria Police, including implementing a falls risk assessment for people being held in custody and updating police training in line with the 1991 Royal Commission into Aboriginal Deaths in Custody.

English also reinforced a recommendation she made early in the inquest at the end of 2018, that public drunkenness be decriminalised in the state of Victoria, which has been accepted and agreed to by the State Government.

The Victorian Government has previously said it has plans to replace the offence with a health-based response.

While the Coroner said she didn’t believe there was evidence to “make a finding the differential treatment was due to Ms Day’s Aboriginality”, she did find the V/Line train conductor, Shaun Irvine, who called for her removal was influenced by unconscious bias.

“[Ms Day] was the only sleeping passenger he has ever called police to remove from the train, although he comes across three sleeping passengers a week,” English said.

The Coroner said his preference to call police over other options was “influenced by her Aboriginality.”

In December 2017, Ms Day fell asleep on the train under the influence of alcohol on her way to visit family. V/Line transport officers escorted her off the train at Castlemaine station where she was later picked up by local police.

Ms Day, 55, was then taken to the local police station and held in custody, where she was inconsistently checked on over several hours.

The harrowing footage released publicly at request of Ms Day’s family during the inquest shows Ms Day stumbling around in her cell, falling and hitting her head against the wall and on the floor several times.

Ms Day would later die from the brain haemorrhage injuries she sustained during those falls.

Ms Day’s family released a statement shortly after the findings were delivered, saying this was the beginning of justice for their mother.

They restated English’s conclusion that police should have sought medical care for Ms Day and welcomed the decision to refer two police officers for investigation.

“The Coroner found that once Mum was in the cell, the police failed to properly check on her, treated her with complacency and breached her human rights to humane treatment and dignity,” the statement read.

“We are pleased that the Coroner found that the V/Line conductor acted in a racist way, but we’re disappointed that the Coroner stopped short of finding that Victoria Police were influenced by systemic racism.”

Ms Day’s family also took the opportunity to reflect on the justice system’s treatment of First Australians.

“While there are sparks of justice in today’s decision, this country has so much further to travel.

“For as long as Aboriginal people are targeted by police, are locked up and mistreated, and continue to die in police custody, the fight for true and complete justice for our people will be ongoing.”

By Hannah Cross