Finding into death of Michael Sean Daly
Deceased
Michael Sean Daly
Demographics
21y, male
Date of death
2015-08-22
Finding date
2016-06-28
Cause of death
injuries sustained when struck by train
AI-generated summary
Michael Sean Daly, 21, died after being struck by a train on 22 August 2015 whilst under the influence of LSD. The coroner found he was incapable of forming suicidal intent due to the drug's effects. Clinical lessons: the deceased had no documented mental health issues despite a family history of suicide and anxiety; he had not attended medical care for years, limiting early detection of risk. The coroner noted that whilst train staff complied with procedures, communication delays (11 minutes between initial trespasser report and collision) and failure to immediately notify police of a partially clothed, potentially distressed person represented missed opportunities. The GPS location inaccuracy (800-900m error) meant responding drivers had incorrect hazard information. System improvements in emergency communication and resource location technology could prevent similar deaths.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- under the influence of lysergic acid diethylamide (LSD)
- inaccurate location reporting of trespasser by initial train driver (800-900 metre error)
- 11 minute delay between initial trespasser report and collision
- line controller distracted by concurrent incident on Craigieburn Line
- failure to immediately notify Victoria Police of person in state of undress on railway line
- lack of GPS technology to provide accurate location coordinates
- train controller did not directly contact TD4652 driver before collision
Coroner's recommendations
- Public Transport Victoria should accept and provide requested funding for Metro Trains Melbourne GPS proposal to enable provision of accurate location information about trespassers and other incidents, which may alter outcomes in like events
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 —