Coroner's Finding: PETER Stanley Walter

55y · Male·dilated cardiomyopathy

Stanley Walter Peter, 55, died of dilated cardiomyopathy while in GSL custody at Port Adelaide Police Station. He had presented with alcohol intoxication (0.311% blood alcohol) on arrest and was transferred to GSL custody the following morning. Multiple GSL staff observed signs of concern (unsteadiness, shakiness) but he was last physically checked around 1pm. He died approximately 2:30pm. GSL failed to conduct required 15-minute prisoner checks and no staff member was assigned responsibility for monitoring. The coroner found his death was sudden and would not have been prevented by proper checking, as onset was extremely rapid with little warning. However, GSL's systemic failures in prisoner supervision breached their contractual obligations.