76 results for “induction procedures”
42y · Female·Global cerebral ischaemia in a setting of anaesthesia
… The anaesthetist, Dr McAllister, failed to obtain or ensure a functioning pulse oximeter reading before induction of anaesthesia, despite difficulty obtaining saturation readings while the patient was awake. He adminis…
47y · Male·Hypovolaemic shock due to exsanguination from traumatic rupture of femoral arter…
…atening despite rapid emergency response. The coroner identified systemic failures: inadequate workplace induction despite documented safety policies, insufficient supervision of inexperienced staff, and poor inter-agen…
64y · Male·Multiple injuries sustained in an explosion
…on site. After initial charges largely misfired, Mr Low failed to follow established Australian Standard procedures for managing misfires. Rather than implementing the proper action hierarchy, he drilled a new hole that …
25y · Male·Aspiration pneumonia secondary to methadone toxicity
…ptoms. Critical gaps existed in handover protocols between health and corrections staff, wellbeing check procedures, and failure to detect signs of toxicity. Key issues: no urinalysis before commencing methadone; incompl…
74y · Male·chest injuries sustained in a quad bike incident (driver)
…ing and instruction for quad bike use, leading to improvement notices. The farm subsequently implemented induction training, safe use policies, and standard operating procedures. The coroner found no further recommendat…
19y · Male·Hanging
…clinical lessons focus on systematic information transfer between youth and adult systems, risk flagging procedures, and ensuring appropriate cell placement for identified at-risk individuals, there was insufficient earl…
61y · Male·cardiac tamponade caused by aortic dissection due to hypertension
Harry Coxell, a 61-year-old man with hypertension, presented to Blacktown Hospital with severe sudden-onset chest pain on 31 October 2006. The Emergency Department doctor, Dr H., assessed him as intermediate risk for isc…
41y · Male·closed chest injuries (ruptured hemi-diaphragm with displacement of abdominal co…
…il-safe braking systems on heavy equipment. Better maintenance protocols, employee training on reporting procedures, and mandatory fail-safe braking systems could have prevented this death.
41y · Male·unable to determine
…ources were not engaged for days. Police were inadequately trained in Missing Persons Standard Operating Procedures (SOPs). Although new SOPs implemented improvements, the findings emphasise the importance of immediate r…
22y · Male·drowning secondary to incapacitation from air embolism
…ry to incapacitation from air embolism. Critical deficiencies were identified: Paspaley lacked emergency procedures for diver retrieval and had failed to conduct rescue drills, resulting in chaotic retrieval once the div…
56y · Male·Head injuries - struck by heavy log off truck
…e trained on industry standards and guidelines; site protocols should mandate verification and clearance procedures before unsafe work is undertaken; and when obvious hazards are identified, work should not proceed until…
66y · Male·Multiple injuries due to motor vehicle collision (pedestrian) against a backgrou…
… while one traffic controller was theoretically sufficient, the crew failed to follow established safety procedures: they commenced work before the traffic controller returned to position, the Traffic Guidance Scheme was…
55y · Male·Electrocution
… than systematic hazard identification. Post-incident, improved policies including unloading checklists, induction questionnaires, and 'No Go Zones' training were implemented.
Male·The available evidence does not allow for any finding to be made as to the cause…
…procedural failures in the search response. Key failures included: Security failed to initiate Code Grey procedures; Police and Security reviewed CCTV of wrong entrances and failed to conduct physical searches of fire st…
21y · Female·mixed heroin and alprazolam toxicity
… possession of significant drug quantities at maximum-security Silverwater, where staff failed to follow procedures for reporting suspected contraband to police. At Emu Plains, an intelligence officer identified drug del…
0y · Male·hypoxia due to intrauterine pneumonia and haemorrhage with uterine rupture in a …
A neonate died shortly after birth from hypoxia due to intrauterine pneumonia, haemorrhage and uterine rupture following prolonged rupture of membranes during a planned vaginal birth after caesarean (VBAC). The mother at…
19y · Male·Blunt head injury from being run over by recycling truck
…ide on moving trucks is inherently dangerous, training was minimal, supervision inadequate, and no clear procedures prohibited riding while reversing. Poor footwear and two-step design contributed. A 'job to finish' work…
43y · Male·Hanging
…safer cell design (to eliminate hanging points) may reduce future deaths, though current risk management procedures were considered appropriate. The coroner recommended annual updates on safer cell implementation progres…
43y · Male·Multiple injuries sustained in a motor vehicle incident (passenger)
…enance, inspection, and defect reporting systems. Key lessons: establish robust written defect reporting procedures, ensure timely repair of identified vehicle faults, conduct regular safety inspections, and maintain cle…
39y · Male·neck compression (due to hanging) and plastic bag asphyxia
… his head covered by plastic bags. Costi had a 2009 history of self-harm but was assessed as low risk on induction in December 2012. He was remanded for 351 consecutive days awaiting trial for rape and robbery charges. …
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