Why did she die?

Key points: Tanya Day was removed from a train and taken into custody for being drunk in public

Tanya Day was removed from a train and taken into custody for being drunk in public She died after sustaining a head injury from a fall inside a police cell

She died after sustaining a head injury from a fall inside a police cell A coronial inquest is currently underway

That's the question everyone in Court 1 of the Victorian Coroners Court has been asking over the last two weeks.

Yorta Yorta woman Tanya Day was 55 years old and lying asleep on a train on a mild December Tuesday in 2017, on her way to Melbourne.

Her daughter was due to pick her up when she reached the city.

She never made it.

Instead, a conductor on the train woke her up to check her ticket. Tanya couldn't find it. The conductor says she was inebriated and wasn't making sense.

We now know she'd definitely bought it, but the conductor spoke to the driver about a passenger he'd found drunk on the train.

The situation was phoned in to V/Line Centrol. They contacted police.

The train stopped at Castlemaine, and police took her off. Soon after, she was in a Castlemaine police cell.

Alone in a cell

Space to play or pause, M to mute, left and right arrows to seek, up and down arrows for volume. Watch Duration: 4 minutes 11 seconds 4 m 11 s WARNING: DISTRESSING CONTENT TANYA DAY HITTING HER HEAD IN CUSTODY

For the past two weeks, the Coroners Court has combed through what happened that day and in particular, what happened next.

At about 3:50pm she was processed at the station and led into a cell.

Got a confidential news tip? Email ABC Investigations at investigations@abc.net.au For more sensitive information: Text message using the Signal phone app +61 436 369 072 No system is 100 per cent secure, but the Signal app uses end-to-end encryption and can protect your identity. Please read the terms and conditions.

The court has seen the CCTV footage of her at both spots — she was walking and talking. The walking was clearly unsteady, but she managed it unaided.

The talking, the officers say, was sometimes responsive and sometimes not. There is no independent verification of that. The CCTV does not have any audio.

The footage after that is deeply distressing — there are no neutral words to describe it.



In short — she spent time in the cell sitting on the cushioned concrete bed, sometimes walking around — reeling really — from bed to wall to door and back again. Sometimes she lay down under a blanket.

Tanya Day is checked briefly by a policeman at Castlemaine station. ( ABC News )

At about 4:51pm she stumbled towards the bed and struck her head sharply on the adjacent wall. It was quick. Police say they didn't see it on their monitors.

She reeled again, but this time she was seated on the bed. This time it was because her brain was starting to haemorrhage. The reeling, we now know, was from the shock of the blow.

Eventually she lay down. She never stood up again.

For the next almost five hours she lay in that cell as the bleed in her brain grew.

Police say when they checked her they thought she was simply intoxicated. In hindsight, it's clear that her right arm and leg were slowly becoming unusable.

Every turn and shift favoured them, and eventually they stopped moving entirely.

At 6:39 pm, she rolled off the bed onto the floor. That was where, an hour and 25 minutes later, police went to her.

Soon after that, they called for an ambulance. The first paramedic arrived about 10 minutes later. About half an hour later, after two more ambulance officers attended, a gurney was brought into the cell.

It was 8:55pm before she was wheeled out.

She was taken first to Bendigo Hospital and much later that night airlifted to Melbourne.

She died 17 days later.

Coroner still deliberating

What happened inside that cell has been awful to see, but it's what happened outside that cell that has been forensically raked over throughout the inquest.

The family of Tanya Day were determined for the vision from Castlemaine Police Station to be released.

Tanya Day's children Warren, Apryl and Belinda outside the Coroners Court of Victoria. ( ABC News: Jeremy Story Carter )

"My family and my community believe that the suffering of Aboriginal people is often kept invisible," Belinda Stevens, Tanya Day's daughter, told the coroner.

Everyone who dealt with Tanya after she boarded that train made decisions that formed part of her experiences that day; a day after which she never woke up and ended with her death three days before Christmas.

Tanya Day had recently joined a gym prior to her death. ( Supplied: Day family )

The coroner is looking at those decisions. She is looking at V/Line, Victoria Police and Ambulance Victoria. She is looking at their actions, policies and procedures.

She is also looking at whether systemic racism played a part in any of those.

Why the decision was made to remove her from the train; why she was taken into custody; why Aboriginal support services didn't attend her; how often and exactly how she should have been checked by police according to their guidelines; whether and how that happened; how her medical emergency, once police realised there was a problem, was responded to by all involved — these are all facts for the coroner to determine.

How systemic racism — conscious or unconscious — might have affected any of these is not so easy to identify or quantify. There's no CCTV of that. It's not so black and white.

This will all hang on the coroner's interpretation.

Either way, it will be a landmark ruling in the long history of Aboriginal deaths in custody and how we as a community can put a line under this tragic toll.

The coronial hearings will continue on Tuesday.