907 results for “inadequate supervision”
62y · Female·end-stage heart failure due to cardiac amyloidosis
A 62-year-old woman with end-stage cardiac amyloidosis died from cardiogenic shock approximately 90 minutes after being placed on a Level 1 inpatient treatment order. She had wished to discontinue treatment, reflecting h…
79y · Male·external neck compression as a result of hanging
…ted, in depressive phase, without appropriate clinical oversight. The coroner found the care was grossly inadequate and identified systemic failures in interstate mental health law implementation and clinical coordinatio…
Unknown·Alan Bugden: pulmonary thromboembolism after stroke. Amaru Bestrin: combined dru…
…ted for over 11 hours, dying of combined drug and alcohol toxicity. Both cases expose systemic failures: inadequate toilet cleaning protocols and monitoring, absent technological alert systems, lack of auditing complianc…
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
45y · Male·Cardiorespiratory arrest due to coronary artery disease, severe psychosis requir…
Stanley King, a 45-year-old man with severe psychosis, coronary artery disease, and obesity, died from cardiorespiratory arrest triggered by antipsychotic-induced laryngeal dystonia. Admitted involuntarily for acute psyc…
22y · Male·hypoxic ischaemic encephalopathy as a result of hanging
…mended EEG and specialist review. Upon return to custody, the Justice Health Nurse Unit Manager provided inadequate clinical assessment, failed to obtain the discharge summary, and did not recommend the safer 'two-out' c…
47y · Female·hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric …
Jodie Ann Pearson, aged 47, died from hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric contents during a gastroscopy at Belmont Hospital on 15 February 2016. Critical pre-procedure informat…
35y · Male·Sudden death during restraint in an agitated obese man with coronary artery athe…
Justin Fraser, a 35-year-old male with first-episode psychosis, died in restraint at Frankston Hospital psychiatric ward on 26 October 2007. He was found attempting suicide by hanging, became agitated and threatening, le…
40y · Female·Sudden unexpected death in epilepsy (SUDEP); epileptic seizure
Sharon Beverley Moss, a 40-year-old woman with a long history of epilepsy, died on 17 February 2005 following a period of sleep deprivation ordered to facilitate a sleep-deprived EEG. She was found unresponsive in her ho…
28y · Male·Multiple injuries sustained when struck by a freight train
Jacob Taulelei, a 28-year-old man with long-standing depression, anxiety, and suicidal ideation, presented to St John of God Hospital on 5 February 2020 expressing intent to jump in front of a train. Despite being assess…
39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…
Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…
42y · Female·Hypoxic brain injury due to choking on food, in a person with Cornelia de Lange …
…eces and shoved it in her mouth, she choked and became unresponsive. While the coroner found Ms Lowry's supervision on that day appropriate and Ms Lowry responded correctly to the emergency, systemic failures were ident…
75y · Female·multiple injuries due to or as a consequence of motor vehicle collision
Ruth Capps, 75, died in a motor vehicle collision after drifting into oncoming traffic. She had multiple medical conditions including diabetes, sleep apnoea, chronic back pain, osteoarthritis, and recurrent falls. Despit…
21y · Male·severe head and upper body injuries, due to, or as a consequence of being struck…
…ard uncontrollably, and the propeller struck his head and upper body. Key contributing factors included: inadequate pre-flight inspection after road transport, engine starting at high RPM (cause uncertain—possibly faulty…
Multiple causes across nine deaths; primary causes included rollover with crush …
This is a complex coronial inquest examining nine quad bike deaths in Queensland, with a focus on prevention through regulatory and design measures. Key clinical and safety lessons include: (1) helmet use is critical—33.…
59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…
…ollections with delayed intervention; lack of specialist liver surgeon during post-operative period; and inadequate nutrition for approximately 10 days. While the coroner found post-operative care generally reasonable, i…
47y · Male·Ligature compression of the neck (hanging)
…The coroner found he died by suicide. While finding no systemic failures in medical treatment or prison supervision, the coroner identified a critical care issue: Groth was placed in medical observation on 5 April, expr…
63y · Male·Multiple injuries due to fall from height
A 63-year-old man with Parkinson's disease died by suicide three days after discharge from hospital following reimplantation of a Deep Brain Stimulation (DBS) device. His initial DBS surgery in 2013 was successful, but d…
0y · Male·intrapartum hypoxia due to placental abruption
…'s professional obligations to advocate against the unsafe plan were compromised by her backup role; and inadequate documentation of informed consent for the dangerous decision.
87y · Female·closed traumatic head injury from a fall at standing height; significant contrib…
An 87-year-old woman with dementia, congestive cardiac failure, and diabetes sustained a fatal closed head injury from a fall in her aged care room overnight. The coroner found that the responsible ECA did not perform th…
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