Finding into death of Robert Thoai Dao

73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a fall

A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending paramedics failed to follow Ambulance Victoria spinal injury guidelines, treating it as a simple fall despite dispatch information indicating a potentially dangerous injury. They did not perform neurological examination, moved the patient inadequately, lacked shared decision-making, and allowed cognitive bias and external pressures (rain, traffic queue) to influence hasty extrication. While the paramedics' substandard care likely worsened his injuries, the coroner could not definitively establish it independently caused death given his age and comorbidities. The case demonstrates critical failures in guideline adherence, assessment protocols, and teamwork in pre-hospital care.