905 results for “inadequate supervision”
37y · Male·stab wound to the chest penetrating the heart
…n non-compliance without legal compulsion, failure to elicit suicidal ideation despite clear indicators, inadequate handover of critical clinical information, and deferring medication administration.
31y · Male·Hanging
…ilure to remove a covered CCTV camera for over 24 hours; falsified observation logs after his death; and inadequate staffing (only two officers instead of three minimum). The Risk Assessment Team meeting was poorly condu…
48y · Female·Hypoxic ischaemic encephalopathy due to pulmonary thromboembolism due to deep ve…
A 48-year-old woman with morbid obesity and smoking history presented to a rural hospital with severe hip and leg pain. Over five days across two hospitals, no venous thromboembolism (VTE) risk assessment was performed d…
16y · Male·Hanging (ligature compression of neck)
…n, interpersonal conflict, recent bereavement); brief crisis assessments without follow-up treatment are inadequate; young people presenting with suicidal ideation following peer suicide require intensive engagement and …
24y · Female·Immersion (drowning due to hypoxic brain injury)
Syoko Tsubaki, a 24-year-old Japanese tourist and inexperienced recreational diver, died from drowning on 31 December 1998 after a scuba diving incident at Rottnest Island on 27 December. During an afternoon dive, the di…
54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking
… provision of food to a patient with poor dentition and sedating medications increasing aspiration risk; inadequate continuous monitoring of the seclusion room by CCTV despite a monitor displaying real-time footage being…
28y · Female·complications of epilepsy
…revious incidents; (3) Staff rostering gaps meant untrained DSWs worked night shifts alone when seizure supervision was critical; (4) Epilepsy Management Plans were overly complex with inconsistent documentation across …
40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…
Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensat…
68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…
…the infirmary as recommended; missing his psychiatric appointment due to inflexible lockdown procedures; inadequate medical assessment of chest pain with borderline ECG showing changes from previous baseline, without car…
32y · Male·Valproic Acid Overdose
Mark Bethell, a 32-year-old with bipolar affective disorder and borderline personality disorder, died from valproic acid overdose at a crisis accommodation facility. He was admitted to John Cade Psychiatric Unit followin…
18y · Male·Gunshot wound to chest
An 18-year-old man (Lewis McPherson) was fatally shot by a 17-year-old (Liam Humbles) on New Year's Eve 2012. The coroner found the death was preventable. Humbles had illegally possessed a handgun for months, dealt drugs…
34y · Male·Neck compression by hanging
…supervised access to an open internal door that served as a hanging point. Key clinical lessons include: inadequate reassessment of rapidly changing presentations, over-reliance on verbal denials of ideation without cons…
24y · Female·Exsanguination from injuries sustained while attempting to climb from a height i…
Phoebe Handsjuk, a 24-year-old woman with a history of depression, anxiety, and alcohol abuse, was found deceased in the refuse room of her apartment building on 2 December 2010. The coroner found she entered a garbage c…
0y · Female·Unascertainable
Shar Rose Benfield, a 7-month-old Aboriginal infant born prematurely to parents with significant psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child …
24y · Male·cardio-respiratory arrest due to multi-drug toxicity
Hugh Lisle, a 24-year-old man with severe chronic arthritis, depression, polysubstance addiction and gambling disorder, died in a private psychiatric facility after admission for substance withdrawal management. Death re…
76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed
A 76-year-old woman with chronic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital fo…
35y · Male·multi-drug toxicity
…l refusal, lack of coordinated psychiatric care, failure to escalate severe mental health deterioration, inadequate support during disciplinary proceedings, inappropriate company transfer removing support networks, and i…
47y · Male·Multiple gunshot wounds; discharged by police officer during enforcement of Comm…
…tant schizophrenia and was acutely psychotic during the incident. Critical failures occurred throughout: inadequate risk assessment and planning by police before and during the operation; miscommunication between mental …
56y · Female·multiple blunt force injuries deliberately inflicted
…ng history of violent sexual offences dating back to age 14. Multiple failures contributed to her death: inadequate on-call nursing protocols requiring nurses to work alone and open security cages to male patients withou…
62y · Female·subacute subdural haematoma due to a closed head injury sustained in a fall from…
A 62-year-old woman on warfarin for a mechanical aortic valve sustained a head injury from a fall. A CT scan on day 5 post-injury identified a small extradural haematoma, but the radiologist (Dr J.) failed to report it, …
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