905 results for “inadequate supervision”
29y · Male·electrocution
…gulated training and licensing for elevated work platform operators working near electrical lines, plus supervision guidelines. A criminal charge of manslaughter was committed against the site supervisor Peter John Jans…
4y · Female·drowning
…ter but disappeared during an evening beach visit. The coroner emphasised critical lessons around child supervision at beaches, particularly for children under 5 years with limited water safety experience. Key preventab…
14y · Male·Complications of near drowning - severe hypoxic brain damage and subsequent mult…
Abubaker Aziz, a 14-year-old non-swimmer from Pakistan, drowned at Coburg outdoor municipal pool on 30 December 1998 after being in the diving pool undetected for approximately 20 minutes, and died from hypoxic brain inj…
35y · Male·pulmonary thromboembolism due to left deep calf vein thrombosis complicating lef…
…protocol was never achieved at therapeutic anticoagulant levels. Contributing systemic failures included inadequate supervision of the intern by registrars, lack of clear accountability for intern supervision, and no tim…
36y · Male·Drowning
…gstanding suicidal ideation before assessment, preventing appropriate risk exploration; inconsistent and inadequately communicated risk assessments among clinical staff; failure to physically search the patient or remove…
24y · Male·unascertained
…e died in unknown circumstances. This case highlights risks in institutional care settings, particularly inadequate supervision of vulnerable residents with complex medical needs and the consequences of isolation as a ma…
3y · Male·drowning
… four other children at the pool complex stating she would return within 30 minutes, but left him under supervision of his 14-year-old sister only. Matthew entered the deeper main pool unnoticed and was found unconsciou…
9y · Female·severe head injuries sustained in a mobility scooter accident
….3 metres over a ridge. Neither child wore helmets. The coroner identified multiple preventable factors: inadequate supervision of young children operating an unsuitable vehicle, failure to restrict access to dangerous t…
1y · Male·Drowning
…tified this as a tragic accident with no suspicious circumstances. Key clinical lesson: active parental supervision remains critical even when physical barriers are in place. Toddlers lack understanding of water hazards…
42y · Female·Choking on a food bolus
…port worker at a shared accommodation facility. Despite having a documented meal support plan requiring supervision, small food pieces, and specific precautions to prevent choking, she aspirated food while being supervi…
32y · Female·ischaemic heart disease complicated by upper gastrointestinal haemorrhage
…(black chunks in stool/vomit); failure to obtain serial troponin tests (only one test at admission); and inadequate interpretation of the abnormal ECG showing Q waves suggesting prior cardiac damage. Had either condition…
35y · Male·Unascertained, following autopsy. Likely drowning but circumstances undetermined…
… his ED management. He was found dead in a flooded creek 7 days later, cause undetermined. Key failures: inadequate supervision of an inexperienced intern, lack of senior clinician review prior to discharge, failure to p…
7y · Female·Pneumonia complicating a viral respiratory illness with acute combined drug effe…
…t being prescribed codeine. No evidence identified who administered codeine. Critical failures included: inadequate training for foster carer Ms B and safety network members Mr and Mrs C; insufficient analysis of feeding…
40y · Female·Crush injury to the chest
…trahydrocannabinol at 19ng/mL, consistent with use 1-2 hours before death. Contributing factors included inadequate mobile supervision, lack of driver intoxication awareness among supervisors, equipment design limitation…
8y · Female·Drowning
…own guidelines requiring this. Although minimum staffing ratios were met, the coroner found that actual supervision on the day was inadequate for a child who could not swim. Key recommendations included implementing sta…
5y · Female·Drowning
…e on 27 December 2022 while swimming with a borrowed inflatable ring in shallow water. A brief lapse in supervision occurred when her mother went swimming to a buoy; despite multiple adults present, none maintained cont…
58y · Male·blunt force head injury
… failures included poor communication of his Community Treatment Order (CTO) across healthcare settings, inadequate psychiatric supervision, insufficient clinical information provided to the assessing GP on the day of hi…
4y · Female·Drowning in the waters of Lake Leanyer
…came submerged. The coroner found Lake Leanyer to be an unsafe recreational facility for children due to inadequate fencing, poor signage, lack of supervision, dangerous underwater ledges with algae-covered slopes, and l…
drowning
… 2006 and January 2009. The coroner concluded all deaths were preventable. Contributing factors included inadequate parental supervision, non-compliant pool fencing, gates left propped open, and systematic failures in lo…
64y · Male·Foreign body associated small bowel obstruction
…ke stone he had ingested. Despite a known history of habitual foreign object swallowing requiring close supervision, and previous episodes of foreign body ingestion managed conservatively with serial imaging and monitor…
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