907 results for “inadequate supervision”
Unknown·traumatic injuries (head injuries and multiple trauma) sustained when struck by …
…uring police pursuit on 20 January. The coroner found systemic deficiencies in Victoria Police including inadequate planning, poor leadership, ineffective coordination, and communication failures. Nine recommendations ad…
32y · Male·ligature compression of the neck (hanging) in a man with methadone and methylamp…
…icantly increasing suicide risk in a prisoner with known personality vulnerabilities. The coroner found supervision inadequate regarding drug access. The cell lacked ligature minimisation despite known suicide risk prin…
40y · Male·Gunshot wound to the head, self-inflicted
…-hour police siege at a residential property in Glenroy, Victoria. He was a high-risk sex offender on a Supervision Order who had allegedly assaulted his partner and failed bail. Police held a public media conference on…
33y · Male·Complications of methylamphetamine use
…inated mental health or addiction treatment. The coroner found the death resulted from systemic failures—inadequate wrap-around support, insufficient housing options, poor inter-agency communication, and lack of speciali…
50y · Male·gastrointestinal haemorrhage; haemorrhage from cystic artery post laparoscopic c…
… occasions; misattribution of bleeding to diverticular disease rather than post-operative complications; inadequate investigation of suspected upper gastrointestinal bleeding with gastroscopy not performed when clinicall…
Unknown·Ruby: ligature compression of the neck (hanging); Carly: ligature compression of…
…obson (47) absconded while on escorted ground access and was hit by a vehicle. Common failures included: inadequate individual management and risk management plans, poor discharge planning, failure to involve families an…
28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…
… consultants not on-call. Multiple system failures (lack of dedicated emergency theatre, staff turnover, inadequate phone communication) contributed to an avoidable death.
20y · Male·ventricular fibrillation secondary to electrocution
…ttery-powered alternatives; (3) appropriate personal protective equipment enforcement; and (4) adequate supervision of young, inexperienced workers. A critically preventable aspect was that nearly identical circumstance…
21y · Female·Multiple blunt trauma with acute alcohol toxicity as a significant contributing …
Anne Chantell Millar, a 21-year-old Aboriginal woman, was beaten to death by her partner Gregwyn Green on 28 March 2003 despite a domestic violence restraining order in place since January 2003. Multiple breaches of the …
66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…
… the death almost certainly preventable, highlighting serious deficiencies in MET team consultation and supervision.
21y · Male·Suffocation from hanging
…iod when Camden died (likely around 4:30 AM). The coroner found that the quality of care, treatment and supervision by Mr Black (supervisor), Mr Kelly, Mr Gordon, and Mr Curbishley all contributed to the cause of death.…
Male·Angel Blanco-Puerto: acute heart failure as result of long-standing damage from …
Four men died from acute heart failure after ambulance officers declined or inadequately pursued hospital transport. In Angel Blanco-Puerto, no potentially life-threatening condition was iden…
Male·Head injuries from motor vehicle accident
…was known to Victoria Police communications but not effectively communicated to pursuing officers due to inadequate, inexperienced, untrained radio operators and poor communication systems. The coroner found that had thi…
57y · Male·Bronchopneumonia complicating metastatic and locally advanced primary adenocarci…
…ssment across 98 prison medical visits, was properly transferred to hospital when pain management became inadequate, and was appropriately managed with palliative care at Bethesda Hospital. The coroner found supervision,…
31y · Male·hanging (self-inflicted)
…d arranged urgent psychiatric review and transfer, but Walker was left alone in Unit 7 without adequate supervision or hazard assessment despite known suicide risk factors. The coroner found multiple contributing failur…
86y · Female·complications of femoral, radial and ulnar fractures; antecedent cause Alzheimer…
…ggression toward staff and residents. Multiple clinical failures prevented intervention: behaviours were inadequately documented and communicated to the GP; the assumption that pain caused aggression led to inappropriate…
60y · Female·Respiratory arrest in the setting of aspiration pneumonia; seizures associated w…
A 60-year-old woman with Down syndrome, Alzheimer's dementia, and epilepsy died from respiratory arrest due to aspiration pneumonia after a seizure. A multi-day delay in anticonvulsant medication (phenytoin) occurred due…
22y · Female·plastic bag asphyxia, possibly contributed to by neck compression
A 22-year-old woman with severe depression and documented suicidal ideation died by plastic bag asphyxiation while detained under a Mental Health Act order in a psychiatric ward. She had explicitly stated plastic bag asp…
45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…
A 45-year-old woman died from multi-organ failure following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (1.5 cm) was contained and re…
29y · Male·ligature compression of the neck (hanging)
Brett Ashley Duturbure, aged 29, died by suicide via hanging at Wyndham Work Camp on 14 November 2019. The coroner identified critical systemic failures in the Department of Justice's management of his care. The Departme…
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