907 results for “inadequate supervision”
45y · Male·Intra Abdominal Haemorrhage Associated with Metastatic Carcinoma of the Oesophag…
…arose by natural causes and found no significant deficiencies in his medical care. Issues noted included inadequate communication protocols between hospitals and prison authorities regarding custody procedures, and the d…
8y · Male·hypoxic brain injury and multi-organ failure from drowning
…hypoxic brain injury and multi-organ failure on 20 January. The coroner found that the drain grates were inadequately secured (bolts were missing or ineffective), inspections were infrequent and ad-hoc rather than system…
0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…
…s later), with agreement about delivery need reached at 1:14 pm. The on-call consultant obstetrician was inadequately involved in decision-making and was not present at delivery. Additional delays occurred between decisi…
75y · Female·Septicaemia as a result of lobar pneumonia; congestive heart failure also presen…
…ctly cause death, autopsy findings suggest it hastened mortality by several days. Key failures included: inadequate locum orientation, poor communication and escalation by nursing staff, equipment issues, and the consult…
34y · Male·Gunshot injuries to chest and left shoulder
…rtive management. The coroner found gaps in liaison between prison and community mental health services, inadequate risk assessment, incomplete clinical records, and failure to implement planned follow-up visits. While t…
Ms Till: head injury with probable crush asphyxia; Mr Raabe: head injury
… NT Link failed to verify the correct wind region despite having coordinates and measurement capability, inadequate tie-down designs were provided without engineer certification, an unqualified welder performed critical …
51y · Female·Ischaemic heart disease
Pauline Margaret Dodd, 51, died of ischaemic heart disease at Sir Charles Gairdner Hospital on 4 March 2014. She was an involuntary psychiatric patient with long-standing bipolar affective disorder, complicated by childh…
75y · Female·Abdominal infection following surgery (repair of recurrent umbilical hernia) - s…
Wilma Ray Jones, 75, died of abdominal infection and sepsis following uncomplicated umbilical hernia repair. Post-mortem revealed ischaemic bowel with infarction, likely caused by superior mesenteric artery occlusion tri…
32y · Male·blunt trauma to the chest and abdomen due to crushing by a steel beam
… the pile became airborne and twisted during maneuvering over an embankment. Critical failures included: inadequate risk management when the original method proved unsuitable for sloped terrain; failure to pursue safer a…
0y · Male·failure to thrive due to insufficient caloric intake
…conduct timely interviews or medical examinations; poor record-keeping preventing communication of risk; inadequate staffing and training of inexperienced workers; failure to follow mandatory Police-FACS protocols for jo…
40y · Female·The medical cause of death was unable to be determined. Manner of death: uninten…
…wn psychiatric history despite police providing her name, missing a clear opportunity for admission; (2) inadequate psychiatric assessment that night – the ED doctor did not consult the on-call psychiatrist despite clear…
41y · Female·ligature compression of the neck (hanging)
…ure items (shoelaces) on admission despite policy; insufficient medical reviews by senior psychiatrists; inadequate risk escalation after violent incidents and expressions of suicidality; failure to convene requested fam…
31y · Male·mixed prescription drug toxicity (methadone, fluvoxamine, tramadol, mirtazapine …
Christopher Neil Adams, 31, died from mixed prescription drug toxicity (methadone, fluvoxamine, tramadol, mirtazapine, diazepam) combined with advanced coronary atherosclerotic disease. He had a documented history of opi…
19y · Male·Complications arising from hyperthermia, including total organ failure, rhabdomy…
…nsulation failed to implement heat-stress management protocols, had minimal safety culture, and provided inadequate training. Critical lessons include: workers in high-temperature environments require acclimatisation, re…
71y · Male·aspiration bronchopneumonia as a consequence of traumatic brain injury from a fa…
Kenneth Wright, a 71-year-old prisoner with acquired brain injury and cognitive impairment from a prior suicide attempt, died of aspiration bronchopneumonia in the Advanced Care Unit of Southern Queensland Correctional C…
47y · Female·Neck compression (ligature strangulation)
A 47-year-old woman died by ligature strangulation using pantyhose while in police custody after arrest on outstanding warrants. She had documented mental health issues (depression) and substance abuse history, with a su…
37y · Male·hypoxic encephalopathy due to asphyxia from hanging
…ed to his death. Key systemic issues: entrenched PEN shortage (60% of night shifts unfilled as of 2019); inadequate ED space and environment unsuitable for mental health patients; and insufficient integrated community me…
29y · Female·respiratory depression caused by morphine intoxication on a background of upper …
…naïve, making her vulnerable to respiratory depression. At hospital admission, nursing observations were inadequate: the door was closed, two nurses miscommunicated about monitoring duties, and no observations were docum…
81y · Male·cardiac arrest following neck compression due to hanging
…ng neurocognitive and forensic assessments that were delayed or not completed. Critical issues included: inadequate documentation of psychiatric assessments (the consultant conducted no documented comprehensive assessmen…
39y · Male·neck injuries from being crushed between a hydraulic ram and hydraulically opera…
Kevin Gallagher-Green, 39, died from neck injuries when crushed between hydraulic machinery at BHP Western Port Steel Works while attempting to adjust a tilt table height. The coroner identified multiple system failures:…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.