907 results for “inadequate supervision”
16y · Female·Mixed drug toxicity
…and high-risk behaviours, died from mixed drug toxicity. The coroner identified significant failures in supervision and care coordination. A residential worker was left alone despite her inexperience; the Alcohol and Ot…
Male·Dehydration
… did not effectively record or relay vital information to rescue services. Contributing factors included inadequate water planning by the three boys, insufficient supervision and approval of the expedition by Sydney Gram…
58y · Male·Multiple injuries from crush injury by falling timber stack
Philip Dickson, a 58-year-old experienced timber yard worker, died when a stack of timber approximately 6-7 metres high collapsed and crushed him while he worked in a drying shed. The coroner found the death was preventa…
38y · Male·Consistent with Drowning
…rents, large waves, and dangerous surf. The coroner found the death preventable, identifying key issues: inadequate signage not meeting AS/NZA standards, lack of tourist-targeted water safety messaging, and absence of li…
0y · Male·cardiogenic shock and neonatal encephalopathy
…Critical failures included: failure to insert an arterial line early (only placed 12 hours after birth), inadequate blood pressure monitoring before and during hypothermic neuroprotection therapy, failure to assess basel…
31y · Male·ligature compression of the neck (hanging)
…le. The coroner criticised ongoing deployment of inexperienced probationary constables without adequate supervision.
43y · Male·hanging
…tional centre cell containing an obvious ligature point (exposed metal railings). He was under extended supervision in the community when his 22-year-old son died in 2021, profoundly affecting his mental health. After b…
15y · Female·Unknown - insufficient evidence for finding
…t after police left her at an unsafe address; delayed release of her photograph to media (5 months); and inadequate supervision during her final days in care. The coroner found no medical or mental health issues that wou…
39y · Male·Choking on a food bolus
…Support Services. While staff at his residence implemented appropriate precautions (small pieces, close supervision, drinks with meals), Aurora classified him as an independent eater requiring no one-to-one supervision.…
43y · Male·head, neck and chest injuries when crushed by a metal plate
Richard Carl Barker, aged 43, died when a metal wing plate fell on him after he removed bolts from a hopper on 23 April 2013. He worked as a contractor at BIS Industries. The day before his death, site manager Grantley H…
Male·Multiple crush injuries to the upper chest and neck sustained in a drilling rig …
…damental deficiencies: the stabbing mat lacked structural integrity, the ground was poorly prepared with inadequately positioned drains, crew had no shared understanding of safe racking back procedures, and workers recei…
15y · Female·hypoxic brain damage due to multiple drug toxicity
…espiratory support. Contributing factors included unauthorized visitors accessing the house via windows, inadequate overnight supervision, limited engagement with available counselling and therapeutic services, and the c…
72y · Male·Fire at residential premises; death by burning and/or inhalation of fumes
…rly man with cognitive impairment living in a fire-prone wooden home with a documented smoking habit and inadequate supervision.
16y · Male·complications of ligature compression of the neck (hanging)
… Department's care. Key contributing factors included excessive in-cell confinement (22–23 hours daily), inadequate mental health services despite documented suicidal ideation and prior self-harm attempts, failure to mai…
49y · Male·Complications of a right superficial femoral artery injury (operated) following …
…ourer who had been instructed not to use power tools but did so against direction. Deficiencies included inadequate formal training documentation, lack of Safe Work Method Statements, and equipment defects (missing safet…
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
…ng factor. He died in custody at Parklea Correctional Centre after deteriorating over 8 weeks of grossly inadequate medical care. Key failings included: discontinuation of proton pump inhibitor medication without clinica…
12y · Female·acute septicaemia resulting from osteomyelitis of the left femur
…onduct three-monthly case reviews, and properly re-register the foster carer. Multiple systemic failures—inadequate staffing, poor information systems, failure to recognise cumulative harm, and assumption that kinship ca…
25y · Male·acute heat stroke
…ovember), commanders lacked knowledge of heat illness severity, medical staff (two basic medics without supervision) were inadequately trained and lacked protocols for heat illness management, Safetyman guidelines were …
4y · Male·drowning in a swimming pool
…ing risks to young children, particularly non-swimmers. Prevention through proper barriers and constant supervision is essential. The coroner recommended immediate regulatory reform to require all domestic pools, regard…
71y · Male·Positional asphyxia
… of admission, with staff documenting wandering behaviour and attempts to climb fences. The facility was inadequately secured with internal doors openable from inside and an external alarm disconnected. Despite clear war…
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