Michael John Darmody moved in with his former partner in Frankston North after being released from prison in November 2013 and was subsequently diagnosed with “toxic leukoencephalopathy” related to “previous and recent” drug use.

The 53-year-old was arrested on May 6, 2014 after his partner told police he had held her against her will with a knife.

Mr Darmody was remanded in custody by a bail justice later that night but was transported to the Moorabbin police station due to the cells at Frankston being at full capacity.

He was found unconscious at about 6.05am when police attempted CPR and paramedics obtained a pulse before he was taken to the Monash Medical Centre where he died five days later on May 12.

Coroner John Olle found while it was not his role to apportion blame, there were “inadequacies” in the response of Custodial Health Advisory Line nurse Karyn Hollenback when told Mr Darmody had only grunted when checked on by sergeant Sean Mayne.

“I find that upon Sergeant Mayne informing Ms Hollenback that Michael’s best response was a grunt she should have immediately directed him to ascertain Michael’s conscious state. In not doing so I find her response was not reasonable or appropriate,” he wrote.

“I find Ms Hollenback, in not ascertaining Michael’s conscious state, denied Michael the opportunity of receiving immediate hospital transfer and straightforward medical intervention.”

Mr Olle found Ms Hollenback “did not receive adequate training to prepare her for the role of CHAL nurse”.

“In particular she did not receive specific training regarding the difficulties of the CHAL role in terms of communicating with lay people (in this case police) and understanding how lay people may not appreciate either the signs and symptoms they are seeing or how to communicate those signs or symptoms and how to overcome these barriers to effective communication,” he wrote.

But Mr Olle said, “to her credit”, Ms Hollenback conceded she should have sought to clarify information, asked more questions and tried to get a verbal response other than a grunt.

“Lessons she has learnt have positively influenced her current practice,” he wrote.

When asked during the inquiry if in hindsight she could have asked different questions to elicit information about Mr Darmody’s breathing, Ms Hollenback said “I’ve had a long time to think about it and there are probably other questions I could have asked, like ‘Does it sound like it’s coming from deep in his lungs or up high?’, but at the time, you know, I was just told he had a snotty nose”.

Mr Olle recommended Victoria Police introduce training for custody staff in identifying and communicating signs and symptoms of life-threatening injuries and develop a formal training model for CHAL nurses.