A 59-year-old Aboriginal man died of idiopathic dilated cardiomyopathy in a Darwin police watch house following arrest for the minor offence of drinking in a designated public place. He had severe, documented cardiac disease (cardiomegaly, heart failure) and had been hospitalized twice for cardiac-related issues in the preceding week. While the nursing assessment at booking was adequate given time constraints, a more thorough review of his electronic health records would have identified his significant cardiac risk. The coroner found that arrest for this minor infringement was disproportionate and unnecessary, driven by a new 'paperless arrest' scheme and Operation Ascari II. The case highlights systemic failures: use of preventative detention contrary to Royal Commission recommendations, overrepresentation of Aboriginal people in custody, and operational pressures on watch house staff compromising care. The coroner recommended repeal of the paperless arrest laws, finding them manifestly unfair and irreconcilable with recommendations to use arrest as a last resort.
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