907 results for “inadequate supervision”
Salt water drowning
… enhanced signage, education about coastal hazards (especially for multicultural communities), parental supervision, and potentially extended lifesaving patrols beyond 6pm. The hidden dangers of the groyne—particularly …
1y · Male·hypoxic arrest due to drowning
…lained deviation from plans, the designer's signature on a compliance statement without site inspection, inadequate council oversight, and lack of regular pool safety inspections. This case highlights the critical import…
35y · Male·drowning (immersion)
…tation. Improved maritime safety procedures, specifically mandatory multiple headcounts and proper crew supervision of intoxicated passengers in rough conditions, could have prevented this death.
49y · Male·Unable to determine - most likely entry into water whilst intoxicated, possibly …
…ypothermia versus other). This case highlights the dangers of alcohol intoxication around water hazards, inadequate lighting at maritime facilities, and the importance of supervision of intoxicated individuals near water…
30y · Male·mixed butane, isobutane and propane toxicity
… this information was not accessible to Department for Correctional Services staff responsible for bail supervision. Despite bail conditions prohibiting drug/alcohol consumption and recommendations for psychiatric asses…
70y · Male·Acute coronary occlusion due to extensive coronary atherosclerosis
…ded: a first-year intern (Dr T.) apparently making discharge decisions without documented senior review; inadequate oxygen saturation monitoring documentation (91% room air at admission not clearly improved at discharge)…
28y · Male·multiple traumatic head injuries sustained in a fall from height
…l prevention devices (mesh and harnesses) were not utilised. The coroner identified poor safety culture, inadequate SWMS understanding and implementation, and insufficient supervision as contributing factors. De Jong had…
3y · Female·Drowning
…nsupervised. The pool barrier failed to meet Australian Standards due to multiple deficiencies including inadequate gate latching mechanisms, an insufficiently high fence, a climbable bluestone barbeque integrated into t…
67y · Female·perforated gastric ulcer; morphine toxicity also made a significant contribution
… later from a perforated gastric ulcer, with morphine toxicity significantly contributing. Key failures: inadequate examination and diagnosis; failure to inspect vomitus for blood; inappropriate use of opioids at home; w…
85y · Female·Coronary atherosclerosis with other significant factors being acute bronchitis, …
…gular hoist audits. Clinicians should recognise that new facilities require robust safety protocols and supervision arrangements, particularly when caring for vulnerable residents with wandering behaviours and fall risk…
41y · Male·Hanging
…ound with a noose at a railway station. He was intoxicated and assigned Category 2 special nursing (1:1 supervision). Despite being assessed as requiring involuntary status if he attempted to leave, he was managed as a …
53y · Male·Choking on food bolus in pharynx, with Huntington's disease and coronary atheros…
…bread sandwich while unsupervised in his aged care room. His care plan specified minced moist diet with supervision, but staff left him unattended with bread for two hours. Contributing factors included non-compliance w…
97y · Male·Complications of a fractured left neck of femur (operated), sustained in a fall
…stained a fractured neck of femur. Despite being classified as an extreme falls risk requiring constant supervision and not to be left unattended, he was taken on an outing with inadequate risk assessment, planning, and…
1y · Female·Head injuries from crush force caused by hydraulic massage table lowering mechan…
… had not been adequately trained on preventive measures. Key preventable factors included lack of child supervision requirements, absence of mechanical guards on the table, and inadequate safety communication to both st…
1y · Female·complications of acute bronchiolitis arising from Respiratory Syncytial Virus (R…
… First Nations child died from acute bronchiolitis due to respiratory syncytial virus (RSV) infection in inadequate accommodation following parental separation from domestic violence services. The coroner identified syst…
42y · Male·unascertained
Richard Vanderhelm, a 42-year-old man with a long history of substance dependence, disappeared on 21–24 May 2009 while undergoing community-based detoxification from methadone, cannabis and benzodiazepines at Somers Cara…
46y · Male·Upper airway obstruction due to acute tonsillitis with laryngeal oedema and haem…
…ved initially on antibiotics. On 7 September morning, the treating GP (Dr B.) changed antibiotics due to inadequate response, then left town without arranging handover of care or follow-up supervision with another access…
1y · Female·Consistent with drowning
…ng that adequate barrier fencing would have prevented access. Key clinical and systemic lessons include: inadequate parental supervision of a toddler near water; absence of building inspections by the property manager de…
34y · Male·Multiple blunt force injuries from motor vehicle crash (pedestrian struck)
…ns (particularly hi-vis requirements for vulnerable patients at risk of wandering), the need for active supervision protocols during high-risk periods, and ensuring environmental factors (lighting maintenance) are addre…
35y · Male·pulmonary thromboembolism due to left deep calf vein thrombosis complicating lef…
…sts indicated sub-therapeutic anticoagulation. The errors went undetected for days despite a three-tier supervision structure (intern, registrars, consultant) because no single registrar was assigned to supervise Dr H. …
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