905 results for “inadequate supervision”
17y · Male·Circulatory failure caused by traumatic brain injury from being struck by a log
…re log during a 'Capture The Flag' game at Mount Ainslie, near his school. Key clinical lessons: (1) The inadequate risk assessment processes meant preventable hazards were not identified. (2) Supervision ratios were ins…
25y · Male·positional asphyxia in a man with extensive old hypoxic brain damage, acute ches…
…eeds, the coroner found the standard of care was 'just or barely adequate.' Key clinical issues included inadequate family communication about escalating pain medication, concerns about supervision and observation despit…
7y · Male·Drowning
…low, creating strong currents and unstable sand conditions. The coroner emphasised that effective water supervision of children should occur within five metres maximum, with proper flotation equipment always used. No me…
65y · Female·choking on a tangerine
…ar recommendations for supervised eating and soft diet from speech pathology. Critical failures included inadequate communication of dietary restrictions during handover from the medical ward to the mental health ward, l…
11y · Male·Asphyxia due to crush injuries from quad bike rollover
…rsus manufacturer recommendation of 3-5 psi for off-road use); lack of active riding technique training; inadequate supervision; and intellectual impairment affecting judgment and safety perception. The helmet worn likel…
4y · Male·drowning
… earlier drowning deaths and met RLSSA standards, this death highlights critical lessons about parental supervision. The child gained pool access accompanied by an adult not actively supervising all children in the grou…
9y · Male·drowning
Bailey Patman, aged 9, drowned at Seaford Beach on 19 January 2012 while swimming with friends under inadequate supervision. Bailey was a poor swimmer who had received minimal swimming instruction and was fearful of …
20y · Male·head and neck injuries sustained when struck by train
…nit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Critical failures in supervision occurred: after his first escape, he was not confined to his room despite identified high risks of self…
64y · Male·hypoxic-ischaemic encephalopathy and its complications following cardiac arrest …
… pathologist had recommended supervised oral intake and 20-minute post-meal monitoring, with one-on-one supervision if eating in his room. However, staffing constraints (two carers for nine residents) made full complian…
47y · Male·Myocardial ischaemia as a result of undiagnosed coronary artery disease; cerebra…
…erebral arterial gas embolism from uncontrolled ascent could not be excluded. Critical failings included inadequate in-water supervision (instructor swimming ahead facing away from divers), lack of buoyancy control devic…
35y · Female·Pulmonary thromboembolus and pulmonary infarction
… been more actively excluded through basic investigations (ECG, chest X-ray). Systemic failures included inadequate emergency medicine supervision, lack of guidelines requiring ECG for chest pain, and barriers to accessi…
40y · Male·gunshot wound to head
…ditions on the Notification of Receiving Instruction form without independent medical verification, and supervision during instruction was inadequate to prevent unattended access to the firearm. The coroner recommended …
57y · Female·Haemopericardium complicating ascending thoracic aortic dissection
…he coroner found the diagnosis was missed due to lack of medical knowledge in the treating registrar and inadequate senior supervision. Key lessons: aortic dissection must remain in differential diagnosis for acute back …
2y · Female·drowning
…dered non-functional the locking mechanism shortly after moving in, without realising the consequences. Supervision failed when the uncle opened the glass door for ventilation and the father did not adequately monitor t…
23y · Female·Penetrating and blunt force trauma to the head
…njuries in 2011. Despite prior convictions and imprisonment, the perpetrator was released on parole with inadequate supervision. Ms Ngatai concealed ongoing contact with her abuser from child protection and health servic…
20y · Female·Multiple injuries sustained when struck by train at Lalor Railway Station
…ultation with the ECATT psychiatrist. She was then transferred to cubicle 13 without formal handover or supervision. ECATT review was delayed with no communication about wait time. Stacey absconded within 20 minutes and…
1y · Unknown·Circumstances consistent with drowning
…oung children can drown in shallow water within seconds without making noise, and that a brief lapse in supervision can have tragic consequences. Key lessons include the need for constant active supervision of young chi…
3y · Male·asphyxia secondary to epilepsy
…breathing, CPR was unsuccessful. The coroner identified critical system failures: (1) the carer provided inadequate supervision, attending to paperwork instead of closely watching; (2) despite the mother's warning, the c…
90y · Female·Intracerebral haemorrhage
…ring a shower, enrolled nurse Jennifer Zammit left the deceased leaning on a Zimmer frame without close supervision to locate a commode chair that had been removed from the bathroom. The deceased collapsed backwards, st…
6y · Male·Head injury occasioned when, as an unaccompanied child pedestrian crossing the r…
…to reach his Tae Kwon Do class. He exited his nanny's vehicle and ran onto the road without waiting for supervision or stopping to look. The driver was travelling at the speed limit and had no opportunity to avoid the c…
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