907 results for “inadequate supervision”
64y · Male·cranial fracture and intracranial haemorrhage secondary to blunt force trauma to…
Norman Aldous, a 64-year-old labourer, died from cranial fracture and intracranial haemorrhage after falling approximately 4-5 metres from a roof at a factory workplace. He had been working on roofing activities without …
25y · Female·Ligature Compression of the Neck (Hanging)
… with her anti-psychotic medications in the weeks preceding her death. The coroner found the quality of supervision, treatment and care to be poor, with a complete breakdown in communication and failure to follow Depart…
48y · Female·malnutrition in association with sepsis on a background of end stage multiple sc…
A 48-year-old woman with end-stage multiple sclerosis died from malnutrition and sepsis after her husband, her primary carer, failed to provide adequate nutrition via a PEG tube despite receiving training and instruction…
28y · Male·neck compression subsequent upon hanging
Matthew Spalding, a 28-year-old psychiatric inpatient with borderline personality disorder and recent psychotic symptoms, died by hanging on 25 April 2009. He had been admitted to the Adult Acute Unit at Ballarat Health …
48y · Male·Multiple traumatic injuries
… levels of methamphetamine (1.6 mg/L), indicating significant driving impairment. The coroner identified inadequate training of officers regarding traffic stop powers, pursuit policy communication requirements, and speed…
81y · Male·metastatic rectal adenocarcinoma with infected necrotic sacral ulcer
…that exacerbated pressure injuries; lack of specialised wound care when the wound nurse was unavailable; inadequate nutritional support and hydration; maximal medication dosing contributing to reduced oral intake and del…
Traumatic asphyxia as a result of being buried by soil and a steel beam followin…
…neering consultation, no geotechnical analysis, insufficient expertise in soil stability assessment, and inadequate safety controls around the excavation. The investigation revealed that proper implementation of the Code…
50y · Female·Hanging
…er noted changes implemented by the Magistrates' Court since 2017, including the Professional Wellbeing Supervision Program, refined induction tailored to background and experience, and assigning new appointees to famil…
40y · Male·Asphyxia caused by a seizure resulting from severe alcohol intoxication. Underly…
Paul Meech, a 40-year-old man with bipolar affective disorder, died of asphyxia caused by a seizure from severe alcohol intoxication while in police custody at Hervey Bay watch house. Critical failures occurred: (1) The …
26y · Male·Ligature compression of the neck (Hanging)
…. The coroner identified systemic failures: delayed psychiatric assessment despite known mental illness, inadequate cell checks by night officers who failed to detect his body until post-mortem, inappropriate cellmate pl…
83y · Female·meningitis with sepsis with the likely source of infection being a large and dee…
…upport services were engaged despite availability. The coroner found evidence of carer neglect including inadequate medical care, poor nutrition, neglected hygiene, and absence of prescribed medications. While not intent…
26y · Male·Neck injury from falling glass crate
…ork in the fall zone. Critical failures included: no written protocols or Job Safety Analysis documents, inadequate task-specific training, lack of toolbox meetings before hazardous tasks, and failure to reinforce safety…
19y · Male·acute bacterial meningitis with secondary cerebritis (meningococcus)
Adam Fabre, a 19-year-old with fever, severe headache, neck pain, muscle pain (10/10), vomiting, tachycardia and blanching rash, presented to Casey Hospital ED at 3:45am on 14 July 2006. Despite expressing clear concern …
71y · Female·cardiac tamponade due to ascending aortic dissection
…obvious' by independent reviewers. The radiologist should have also warned that non-contrast imaging was inadequate to exclude dissection. Mrs Rogers died from cardiac tamponade that night. Immediate surgery (Bentall's p…
36y · Male·Shotgun wounds to the chest and abdomen
…ious criminal conduct. The coronial investigation examined whether systemic failures in Khayre's parole supervision, management or monitoring by Corrections Victoria, the Adult Parole Board, Victoria Police and the Comm…
19y · Female·Head injury
Brodie Panlock, a 19-year-old waitress, died from head injuries sustained when she jumped from a car park after experiencing systematic bullying and psychological abuse by management and coworkers at her workplace cafe. …
48y · Male·Injuries sustained in an explosion
Glenn Sanders died from injuries sustained in explosions on his property during a police siege. Sanders had severe mental illness (Delusional Disorder/Schizophrenia), polysubstance abuse, and had rigged his house and far…
0y · Female·hypoxic brain injury following respiratory arrest due to accidental suffocation …
…o child protection services (CPS) due to intellectual disabilities, severe parental alcohol abuse, poor supervision, and neglect. Fifteen notifications had been made before the infant's birth, but CPS failed to conduct …
32y · Male·Hanging (deliberately self-inflicted)
… that had police communicated Fred's intentions, he would have been placed under Risk Intervention Team supervision in the clinic with camera monitoring rather than segregation. While alternative management's preventive…
24y · Male·Unknown; most likely died in single vehicle accident in Brisbane River
…ility and circumstantial evidence. Initial civilian police investigation by Detective Shayne Maxwell was inadequate, with minimal work over 12 years. A 2017 police task force conducted thorough searches but found no vehi…
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