907 results for “inadequate supervision”
24y · Male·inhaled solvent toxicity (from petrol sniffing)
Edward James Laurie, a 24-year-old man with chronic petrol sniffing addiction since age 10 and underlying mental health issues including psychosis, died from inhaled solvent toxicity on 11 October 2015. Sixteen Applicati…
48y · Female·Mixed drug toxicity (morphine, codeine, venlafaxine, amitriptyline and zopiclone…
…rate, importance of comprehensive bag searches after leave, and clear protocols for 'responsible adult' supervision during accompanied leave. The hospital lacked expertise in substance abuse management and should have s…
56y · Female·hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and f…
…cted by Dr D. Multiple contributing factors included: difficult airway anatomy, chaotic MET environment, inadequate team leadership and communication, failure to promptly utilise capnography monitoring (gold standard), a…
63y · Male·Drowning
…t review for four months despite worsening mental state and non-compliance; and over-reliance on family supervision without assessing their capacity. The coroner found the care was not proactive, consultative, or focuse…
89y · Female·Blunt force head injury on a background of ischaemic and valvular heart disease
… found that with proper risk management, the death could have been prevented. Systemic failures included inadequate behaviour risk assessment, inconsistent incident recording, normalisation of aggressive behaviours, and …
1y · Female·sudden unexpected death in infancy due to hypoxic episode while co-bedding with …
…hile breastfeeding promotion is important, safety protocols must be enforced with adequate staffing and supervision; (5) mothers who are extraordinarily tired, sedated, or have altered consciousness should not bed-share…
15y · Male·compression of the neck by hanging
…tober 1999, leading to an unnecessary sentence and subsequent similar sentencing on 18 January 2000; (2) inadequate court representation and prosecutorial assistance at remote bush courts; (3) insufficient training of Do…
20y · Male·acute blood loss from extensive crush injury to torso following an industrial ac…
…lan was prepared, no building permit was issued before work commenced, and the apprentice lacked proper supervision and hazard protection. The coroner found that proper site inspection, inclusion of the chimney in desig…
68y · Female·Coronary heart disease
… re-presented 48 hours later in acute pulmonary oedema and died despite resuscitation. Clinical lessons: inadequate length of stay for diagnostic clarity in acute heart failure; failure to act on abnormal vital signs and…
21y · Male·multiple injuries from fall from water tower
…e attempt, and the unrealistic expectation that a non-medically qualified father could provide adequate supervision. The coroner endorsed this criticism while noting suicide risk assessment is inherently difficult. Key …
7y · Male·Joshua died due to a combination of physical entrapment of his head which occlud…
…ent. While the registrar could have recognized Joshua required more frequent observations or continuous supervision given his mobility and inability to call for help, neither medical nor nursing staff had appreciated th…
30y · Female·Fentanyl overdose caused by self-administration of intravenous Fentanyl
… screen for oxycodone despite Fentanyl misuse history; lack of real-time access to prescription records; inadequate communication between treating psychiatrist and psychologist regarding self-harm behaviour; and healthca…
0y · Male·Burns from fire
…dated demountable building provided no protection. The coroner found no culpability; the death reflected inadequate supervision of a young child accessing hazardous equipment.
62y · Male·hanging
…res in communication between hospital staff and the civilian escorts regarding the nature and extent of supervision required. Escorts were not given adequate information about their responsibilities, crisis management p…
4y · Female·closed head injury with contributing extensive subcutaneous and intramuscular ha…
…ilure to utilise available protective tools (family care meetings, investigation and assessment orders), inadequate investigation of 22 notifications, misinterpretation of confidentiality and investigative powers, reluct…
76y · Female·multisystem organ failure due to or as a consequence of ischaemic small intestin…
A 76-year-old woman presented to hospital with abdominal pain and was found on CT scan to have ischaemic colitis with signs of profound shock. The Consultant Surgeon decided on conservative management with fluid resuscit…
29y · Male·Ketoacidosis as a consequence of diabetes mellitus (Type 1)
…vere intellectual impairment and epilepsy but was described as able to 'self-manage' his diabetes 'with supervision'—a characterisation that proved dangerously inaccurate. Critical failures included: lack of independent…
12y · Male·Head, chest and abdominal injuries sustained when run over by a vehicle
…d without handover; failure to implement the strap-and-rope safety separation used in earlier years; and inadequate identification of obvious hazards by supervising staff. The coroner found the setup manifestly dangerous…
74y · Female·Fractures of the legs, with terminal palliative care, in an elderly lady with mu…
…ap-sash straps due to poor equipment storage organisation, then made a clinical decision to proceed with inadequate restraint rather than remove the resident from the vehicle. The critical failures were: inadequate restr…
47y · Female·Multiple injuries from being struck by a train
A 47-year-old woman with major depressive disorder and anxiety died by suicide while an involuntary psychiatric inpatient. She had attempted suicide in November 2014 and was admitted to Bentley Hospital for psychiatric t…
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