907 results for “inadequate supervision”
70y · Male·bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidi…
… clinical issues included: (1) unauthorised self-administration of oxygen from Oxiboots without medical supervision, which masked deterioration and delayed recognition of acute coronary syndrome; (2) repeated refusals o…
86y · Male·head injury (acute intracerebral haemorrhage and subarachnoid haemorrhage)
…senior review after in-hospital falls in elderly patients on anticoagulation, and implement appropriate supervision protocols for high-risk patients.
36y · Male·Toxic overdose of Clozapine (anti-psychotic drug), self-administered, with termi…
…severe disorganisation, lack of food, marked weight loss) to the psychiatrist; medication monitoring was inadequate—Clozapine dispensed in 4-week batches without proper oversight despite known non-compliance history; and…
68y · Male·coronary atherosclerosis worsened by heat stroke
…chlorpromazine) known to impair temperature regulation and sweating. Key preventability factors include: inadequate staffing (one carer for 31 residents on a weekend); no hydration policies for extreme heat; facility wit…
47y · Male·ligature compression of the neck (hanging)
…his death. Mental health care was adequate given resources and COVID-19 restrictions. However, critical supervision failures occurred: the night shift officer conducting the final cell count failed to account for all pr…
24y · Female·Shotgun injury to the head
…nce to determine manner of death. Key failures included: premature PFA lifting, allowing scene cleaning, inadequate detective response to uniformed officer concerns about suspicious circumstances, lack of forensic field …
18y · Male·methadone toxicity
…oom checks despite documented drug use at the facility; staff unaware of methadone-prescribed residents; inadequate monitoring systems; poor communication of absence protocols; delayed and inadequate police investigation…
4y · Female·Hypoxic ischaemic encephalopathy following immersion
A 4-year-old girl drowned in a neighbouring pool after crawling through a gap in a shared boundary fence that served as a pool safety barrier. The fence had been certified as compliant in February 2024 but deteriorated s…
Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…
Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following over…
2y · Female·drowning
…intervention could have prevented the death. Systemic failures included poor inter-agency communication, inadequate supervision of junior staff, absence of psychiatrists from multidisciplinary team meetings, and lack of …
46y · Male·self-inflicted hanging
…e, finding that his treatment and medication were appropriate. However, systemic issues were identified: inadequate nursing staff qualifications and ratios (one registered nurse with two untrained patient care assistants…
17y · Male·Head injury
… unsafe position throughout transport. The coroner concluded the death was preventable and resulted from inadequate vehicle design, lack of safety protocols, and failure by the Police Service to address known hazards ide…
83y · Female·unascertained
…isabilities, dementia, and inability to independently manage a marine emergency. Critical issues include inadequate medical assessment of her fitness for such a voyage, absence of capacity evaluation or safeguarding deci…
26y · Male·bronchopneumonia following severe head injury
…g height (910mm vs current 1000mm minimum). Critical clinical failures included: lack of proper medical supervision (phone-only handover with on-call doctor who never attended hospital), failure to establish a care plan…
54y · Male·hypoxic-ischaemic encephalopathy resulting from neck compression due to entrapme…
…1) absence of a Safe Work Method Statement (SWMS) for the scissor lift work; (2) unsafe work method with inadequate workspace (360mm×620mm); (3) emergency lowering lever positioned flush against a safety fence, making re…
56y · Male·Head injuries sustained in a fall from a height
…y 2.7 metres to concrete, striking his head. The coroner found the ladder was deficient, the work method inadequate, personal protective equipment (helmet and safety glasses) was not worn or enforced, and the Safe Work M…
19y · Female·Unknown – not determined
…eral shortcomings in the initial missing person investigation, including lack of formal risk assessment, inadequate supervision, and delay in reporting to the coroner (21 months). The coroner recommended the case be refe…
14y · Male·gunshot wound to the head
…eriods, was an acknowledged alcoholic, and had no control over Andrew. The relative carer assessment was inadequate, conducted without observing child-carer interaction or consulting Andrew's wishes. When Andrew went mis…
17y · Male·Cerebral ischaemia caused by hanging at Quamby Youth Detention Centre at approxi…
…ember 1996 around 6.30am and died from brain death on 21 September. The coroner found critical failures: inadequate keys policy preventing immediate room access, poor documentation and handover systems, failure of specia…
74y · Female·Multiple injuries sustained when struck by train
…icidal. In the ED, she was appropriately assessed as requiring admission under the Mental Health Act but inadequately supervised. A psychiatric registrar informed an unidentified nurse that she was detained on forms, ass…
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