Inquest into the death of Hugo Peter Diaz Knox
Deceased
Hugo Peter Diaz Knox
Demographics
25y, male
Date of death
2022-09-30
Finding date
2026-08-20
Cause of death
Cardiorespiratory arrest due to acute cocaine toxicity
AI-generated summary
Hugo Diaz Knox, 25, died from cardiorespiratory arrest due to acute cocaine toxicity following his arrest for a positive roadside drug test. The coroner found he ingested a massive, fatal dose of cocaine (35mg/L blood concentration, among the highest ever recorded) while in police custody. Although the coroner determined his death was not preventable given the toxin dose, critical procedural failures were identified. A police officer observing Hugo in custody failed to recognize or report concerning clinical signs—falls and tonic-clonic seizures—and did not provide basic first aid or alert colleagues. Medical assistance was delayed until obvious deterioration occurred rather than at initial signs of intoxication. The inquest highlighted failures in police protocols for recognizing drug intoxication. The coroner recommended policy amendments to clarify that police must immediately seek medical attention when drug ingestion is suspected, regardless of ingestion route.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Ingestion of massive quantity of cocaine (35mg/L blood concentration)
- Failure of police officer to recognize clinical signs of cocaine intoxication
- Failure to report or alert colleagues to Hugo's falls and seizures
- Failure to provide basic first aid or place in recovery position
- Delay in calling for medical assistance until obvious deterioration
- Inadequate face-to-face observation during custody transport
- Insufficient supervision in rear custody pod
- Lack of CCTV or video monitoring in police custody vehicle
- Gaps in police policies and procedures for drug ingestion in custody
Coroner's recommendations
- The Commissioner of Police consider the referral of this matter to the New South Wales Police Professional Standards Command for the investigation and review of the conduct of Senior Constable Cameron Smith
- The Commissioner of Police give consideration to reviewing section 10.25 of the Person Search Procedure V3 with a view to clearly stating that medical attention should be immediately sought where police suspect a person has ingested, consumed or administered, by any means, drugs or a harmful substance
- The Commissioner of Police give consideration to reviewing the Charge Room and Custody Management Standard Operating Procedures with a view to include a procedure that medical attention should be immediately sought where police suspect a person has ingested or consumed, by any means, drugs or a harmful substance while in police custody
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —