Jay Maree Harmer, 38, who suffered from incurable liver disease, was found dead by her 21-year-old cell-mate, who was also Ms Harmer's prison carer, at Brisbane Women’s Correctional Centre on July 2, 2016.

Eight days before her death, Ms Harmer was transferred to the Princess Alexandra Hospital’s secure unit after a doctor at the BWCC became concerned about her deteriorating condition.

But despite advice to remain in hospital and transfer to a palliative care facility as a parolee, Ms Harmer insisted she wanted to return to BWCC as she viewed it as “her home”.

She was discharged against medical advice and returned to BWCC on June 28.

The coroner heard on the day she was admitted to hospital, BWCC general manager Kate Holman asked the Parole Board for advice on making an ‘exceptional circumstances’ parole application on her behalf.

However, the coroner noted the application was deferred by the Parole Board to obtain a specialist opinion, despite there being a doctor’s report which was tendered at Ms Harmer’s sentencing hearing, and an email from her doctor on June 24 outlining her deteriorating condition.

The coroner heard evidence from Parole Board Queensland deputy president Peter Shields that the doctor's email alone may have led to the granting of Ms Harmer’s parole, had they received it.

The Parole Board also did not receive a copy of the prisoner’s medical report from her sentencing hearing because Queensland Corrective Services did not have the report on its file at the time her parole application was made.

At the inquest, Ms Harmer’s family said Ms Holman should have attached the doctor’s email of June 24 to the parole application that was lodged.

“The fact Ms Harmer was not released to parole prior to her death represented a missed opportunity for her to reconnect with her family before her death, and to die in accordance with a palliative care plan that she might have been engaged in preparing,” state coroner Terry Ryan said.

“I agree with the family’s submission that the information submitted to the Parole Board was not the best available evidence.

“Unfortunately, this reflects the reality that an application for parole was not made by Ms Harmer or anyone else on her behalf at an earlier time during her final period in custody, when better quality material could have been presented in support of the application.”

Mr Ryan said he would make “no adverse comments” in relation to the email not being sent, and noted that the prisoner had been made aware of her right to apply for parole from early 2015, but had elected not to do so.

In his report, the state coroner recommended that:

A spokesperson for Queensland Corrective Services said: “QCS is presently carefully considering the recent recommendations of the coroner to determine how they can guide improvements in our processes and practices.”

Debbie Kilroy of Sisters Inside said applying for parole was difficult for many female prisoners.

“We have women who can’t read and write, so, they can’t even do a parole application,” she said.

“If you don’t have the skills or the resources, or don’t have family to go and live with, it’s difficult to find accommodation in the community.

“The reality is, prison services don’t care if a woman is past her eligibility date. They’re not held accountable for it. This is why we have massive overcrowding as well, and why now they’re using [it] as an excuse to open a new women’s prison.

“This is why we require significant funding to do the work we’re doing, that we’re doing for free, to get women out of prison past their eligibility date.”

Ms Kilroy says cases where prisoners had gone far past their parole eligibility date, served to highlight how the system was failing inmates.

“Terminally ill women like Jay would be out getting the appropriate health care, palliative care and be home with their family,” she said.

“For other women, it’s about getting them out of prison when they’re eligible, as determined by a court of law, not by the court of corrective services.

“A court of law sentences someone, and when the court deems you eligible, that’s when you should be released - not wait until after the fact.”