907 results for “inadequate supervision”
89y · Female·Ischaemic heart disease in a woman with a history of recent assault
…adequately supervise a known violent resident despite previous assaults documented three days prior; (3) inadequate staffing ratios (1 staff to 7-14 residents) prevented protective measures; (4) care plans were not pract…
54y · Female·Hanging
…ic experience, conducted minimal direct assessment herself, and failed to communicate leave conditions, supervision requirements and crisis planning to the primary carer. Communications fell short of good clinical pract…
68y · Male·head injury from crush trauma between forklift mast components
…erators using unregulated grey-import machinery, complete absence of safety management systems, lack of supervision, the dangers of using mobile equipment as work platforms, and the lethal consequences of poor workplace…
62y · Male·Brain swelling associated with cerebral infarction; drainage acute on chronic su…
… and died. The coroner identified failures in vehicle safety procedures, driver training standards, and supervision of casual staff. Key preventability factors included unsafe unloading procedures, failure to engage the…
1y · Unknown·Head and neck injuries and motor vehicle incident (pedestrian)
…r friends, and affect children under six years old. Key preventive measures identified include constant supervision of young children in driveways and ensuring drivers know the location of children before operating vehi…
49y · Male·Complications of penetrating sharp force injuries through the chest and abdomen …
…n notification. While hospital treatment was appropriate, the coroner found systemic failures in parole supervision—specifically, gaps in required urinalysis testing over three months and delayed drug counselling commen…
23y · Male·Head injuries (skull base fractures and parenchymal brain injury sustained in fo…
… causing fatal head injuries. The coroner found the death preventable, resulting from multiple failures: inadequate propping (wooden beam instead of proper props), failure to check that level 7 was clear, inadequate barr…
88y · Female·Head injury in a fall due to atrial fibrillation on anti-coagulants
…is essential in high-risk patients; nursing students require explicit education on falls management and supervision frameworks; and inconsistent practice by senior staff undermines patient safety protocols. The hospital…
5y · Male·Hypoxic ischaemic encephalopathy due to near-drowning
…opathy. Critical factors included: parents' inability to read English or swim, lack of understanding of supervision requirements despite pictorial signage, no physical barrier between shallow and deep pools, and relianc…
45y · Male·exsanguination due to incised wound to neck
…tion rounds were not mandatory, allowing Mr McCarty to avoid contact with staff; (5) welfare checks were inadequate during morning unlock periods—staff spent extended time at the station rather than patrolling. Had prope…
88y · Female·Complications of fractured neck of femur
… the patient deteriorated over 6 weeks before dying on 12 July 2018. Clinical lessons include: adequate supervision and monitoring of aggressive residents is essential in locked dementia units; early recognition of assa…
66y · Male·Multiple injuries due to motor vehicle collision (pedestrian) against a backgrou…
…e Traffic Guidance Scheme was not completed, and the illuminated arrow board was not deployed. Critical supervision failures existed—the night-shift crew had minimal oversight from their day-shift supervisor. The corone…
2y · Male·Cardiac and respiratory arrest consequent upon accidental immersion and drowning…
…re not certified and the pool gate lacked a self-closing mechanism—the coroner emphasised that parental supervision remains non-delegable. Key clinical lessons: constant vigilance is essential around water, young childr…
3y · Female·Drowning
…ool in Broken Hill on 30 November 2009. The coroner found the death resulted from two critical failures: inadequate supervision of the young child and non-compliance of the pool with safety standards under the Swimming P…
80y · Male·metastatic oesophageal cancer
…isiting (one visit weekly initially), inappropriate food provision inconsistent with dietary orders, and inadequate supervision during two unwitnessed falls in February 2021 at night. While his cancer was incurable and p…
33y · Male·Injuries sustained when the Air Trac drill rig toppled over workbench 345, slidi…
… mast extended, causing it to tip over an 11-metre drop. Critical clinical-occupational lessons include: inadequate training documentation systems for equipment operators despite on-the-job experience; absence of formal …
31y · Male·accidental overdose of fentanyl
…le weeks. The coroner noted this was a low-security rehabilitation facility where prisoners had reduced supervision during work duties, balancing rehabilitation goals against security risks.
19y · Female·severe head injury due to fall during gymnastics on Tumbl Trak, striking uncover…
…om cannabis use, which adversely affected psychomotor function and judgment. Critical failures included: inadequate hazard assessment of adult use of the apparatus, removal of protective scatter matting from the landing …
31y · Male·hanging
…ant approval documented in medical records, allowed discharge with a plan involving parental medication supervision and follow-up with CATS. The discharge plan lacked proactive CATS referral despite Christopher's treatm…
Female·Drowning (suicide)
… basis without adequate supply or medical oversight, leading to clear deterioration; family members were inadequately briefed on suicide risk and their supervision responsibilities; and critically, when Ms Blake's condit…
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