905 results for “inadequate supervision”
1y · Female·Drowning
…access through an unsecured gate with a broken, non-self-locking mechanism. The coroner found that while inadequate supervision was a contributing factor, the critical failure was non-compliant pool fencing. The pool, co…
Unknown·Explosion injuries and carbon monoxide poisoning from methane gas ignition in un…
…ventilated B heading stub during a planned ventilation system changeover. Contributing factors included: inadequate communication of changeover procedures to deputies and workers; failure to remove a planned brattice sto…
Male·Multiple injuries as a result of being struck by a Track Machine in a railway in…
… December 2007. The Coroner identified multiple contributing factors: defective lighting on the machine, inadequate pre-start checks, absence of safety briefing and proper track protection, lack of communication between …
25y · Female·acute haemorrhage due to severed femoral artery caused by a stab wound to the th…
Sasha Loreen Napaljarri Green, 25, died from acute haemorrhage due to a severed femoral artery from a stab wound to the thigh, found in scrubland near Tennant Creek in November 2013. The coronal investigation identified …
45y · Male·Combined drug toxicity (methadone, amitriptyline, gabapentin, paracetamol)
…ison's 'trap-to-trap' medication dispensing method (medications passed through cell door traps) provided inadequate supervision for identifying and preventing drug accumulation. Evening lockdown procedures did not reliab…
26y · Male·shotgun wound of the chest
…ory of self-harm, escaped from Royal Hobart Hospital on 2 January 2023 while under correctional officer supervision. He had been admitted for ingestion of foreign objects. Two correctional officers failed to follow secu…
2y · Male·accidental drowning
…pervisory responsibility among childcare staff; children were not counted when exiting the pool complex; inadequate supervision during the transition from swimming area to changing facilities where the child became separ…
30y · Male·head injury sustained in a fall after being struck by crowd controller Henry Von…
…utable to crowd controllers. Training was purely classroom-based with no probationary period, workplace supervision, or substance testing. Recommendations focused on improving training standards, implementing probationa…
8y · Male·Drowning as the result of a motor vehicle accident
…dren drowned following a motor vehicle accident on the Stuart Highway after a grouser plate fell from an inadequately restrained load on a road train, puncturing their vehicle's tyre and causing loss of control. The pall…
77y · Male·multiple chest injuries
…ader with the mast elevated (contrary to explicit instructions), not wearing the available seatbelt, and inadequate workplace safety oversight. The coroner found the death entirely avoidable, emphasizing that proper trai…
95y · Female·Incised injury to the neck
…e facility security—particularly unsecured external access points, lack of lockable resident room doors, inadequate night-time staffing supervision, and the ability for residents to be isolated from staff assistance. The…
19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …
…d this: Mr Rolfe had a history of excessive and unnecessary force against Aboriginal detainees that went inadequately supervised; racist attitudes were normalised among police; communication breakdowns occurred in IRT de…
85y · Female·Coronary artery disease and heat exposure
… monitoring despite government warnings about extreme heat risks to elderly residents. Police search was inadequate: officers failed to search adjacent Bogong Park where her body was later found, did not establish accura…
32y · Male·overdose of a combination of chlorpromazine, mirtazapine, and diazepam
…ces between hospital discharge and community management; and importance of not relying solely on family supervision when ongoing psychiatric symptoms persist despite reassurance they would improve.
46y · Male·neck compression due to hanging
…ade Sulley, aged 46, died by hanging while on home detention under Department for Correctional Services supervision. He had a significant psychiatric history including previous suicide attempt by hanging (1997), prior s…
Male·Unrecognised pulmonary hypertension in a setting of unsafe sleeping conditions
…including the inappropriate bassinet, prone positioning, extraneous bedding, absence of ventilation, and inadequate supervision—likely contributed to his death by triggering acute respiratory distress. The educator's CPR…
24y · Male·self-inflicted hanging
…ilures included: absence of approved leave procedures (despite legislation requiring them for 17 years), inadequate risk assessment failing to recognise psychosis as a static risk factor, minimal discussion with parents …
32y · Male·Gunshot wound to head (self-inflicted)
…: Community Corrections failed to promptly notify the Parole Board of domestic violence allegations and supervision breaches; police call centre staff handled a domestic violence report inadequately without identifying …
26y · Male·gunshot wound to the neck
… bullet hitting Crews in the neck causing unsurvivable vascular injuries. Systemic failures contributed: inadequate risk assessment methodology, poor supervision of planning, lack of uniformed officer visibility for iden…
17y · Female·mixed drug toxicity
…revious methadone and other CNS depressants (doxepin, diazepam, fluoxetine). Critical failures included: inadequate investigation of her complex psychiatric history and previous Melbourne methadone treatment; escalating …
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