Inquest into the death of Robert Daly
Deceased
Robert Taylor Daly
Demographics
38y, male
Date of death
2007-01-26
Finding date
2008-09-01
Cause of death
coronary atherosclerosis
AI-generated summary
Robert Taylor Daly, a 38-year-old Aboriginal man, died of coronary atherosclerosis with severe coronary artery blockage and pulmonary edema. He collapsed in a drinking area after consuming alcohol while acutely ill with a bad cough. Police, believing him intoxicated, took him into protective custody. Although he reported chest pain and shortness of breath, Aboriginal health workers conducted only a brief bedside assessment in the cells and cleared him. He was released the next morning but deteriorated at home and died despite resuscitation efforts at the clinic. The coroner found the death preventable through better clinical judgment: a person complaining of chest pain and dyspnea should be transported to hospital or clinic for proper medical assessment, not assessed in police custody by non-physician health workers. The coroner recommended procedural changes ensuring detained persons with cardiac symptoms receive immediate physician evaluation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- alcohol intoxication appearance mimicking serious illness
- inadequate clinical assessment by non-physician health workers in police custody
- failure to transfer to medical facility for proper evaluation despite reported chest pain and dyspnea
- severe coronary artery disease with 80% blockage of one major vessel and complete blockage of another
- pulmonary edema
- chronic harmful alcohol use and smoking
Coroner's recommendations
- The Commissioner of Police and Department of Health should review legal and administrative procedures applicable to health assessments of detained persons with a view to revision
- Persons complaining of or observed to have symptoms of chest pain or shortness of breath should be sent immediately to a hospital where available or a local clinic and the opinion of a medical practitioner obtained as to the care and detention of that person
- Aboriginal health workers, no matter how experienced or well-trained, should not be put in a position to opine on the health of a person in detention or custody where that person complains of chest pain or shortness of breath
- Video surveillance equipment in police cells and watch houses must be properly maintained and functioning; police officers must be properly trained in operation and maintenance of such equipment
Full text
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