905 results for “inadequate supervision”
44y · Female·Head injury sustained when exiting a moving vehicle
A 44-year-old Filipino woman died from head injuries after exiting a moving vehicle travelling at 100 km/h during an episode of domestic violence. Ms Blackmore had reported non-lethal strangulation and threats to police …
38y · Male·Multiple injuries
Damian Kay, aged 38, died from multiple injuries after jumping from the 16th floor of a hotel on 22 September 2010, with a blood alcohol concentration of 0.71%. The death occurred in the context of recent relationship br…
57y · Male·immersion (drowning) - for Turner confirmed by post mortem; for Carter and Fairl…
…drowned at sea. Critical failures: Turner did not disclose ballast removal to the surveyor; the surveyor inadequately verified information and relied excessively on owner claims; key information about fuel tank capacity …
25y · Female·Chest injuries due to fall from height
…by behavioural management, and died on the day of a Mental Health Review Tribunal hearing. Key failures: inadequate clinical escalation after suicide threats; failure to assess deteriorating mental state; lack of structu…
64y · Male·necrotising fasciitis precipitated by a fishbone perforating his rectum, leading…
James Tranby, a 64-year-old Indigenous diabetic prisoner, presented with a fish bone lodged in his rectum on 3 December 2008. Following removal on 5 December, he developed progressive sepsis leading to necrotising fascii…
16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…
…ng care, placement in an unsupervised cubicle, failure to recognise unconscious bias affecting his care, inadequate escalation pathways, and late NETS involvement. Stronger clinical leadership, earlier senior review upon…
Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…
… agencies under 16 ministers; Department of Indigenous Affairs unable to provide effective coordination; inadequate child protection services; severe truancy (59% of Kimberley students attend infrequently); and insuffici…
0y · Female·Perinatal asphyxia
Poppy Louise Habgood was born at 0100 hours on 10 July 2008 by emergency caesarean section at 42 weeks gestation, weighing 3968g. She was born severely asphyxiated with a heart rate of 60bpm and died at 0126 hours despit…
Female·multiple injuries due to a fall from height (suicide by jumping from multi-store…
A woman with major depressive disorder and psychotic features died by suicide at a shopping centre car park on 21 September 2004, six days after admission to Belmont Private Hospital under an involuntary treatment order.…
0y · Female·Head injury
…ad no formal mental health training despite observing concerning statements. Critical failures included: inadequate escalation of mental health risk despite documented depression screening results, no proactive safety as…
0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia
Bodhi Leo Searle, aged 36 hours, died from hypoxic ischaemic encephalopathy due to intrapartum asphyxia. He was born to a woman in low-risk labour managed initially by independent midwife Stephanie Geyer. When labour did…
37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia
Glen Dooley, a 37-year-old Aboriginal man, died of atherosclerotic heart disease and dyslipidaemia while in custody at Darwin Correctional Centre. His death was avoidable. He had abnormal ECGs in 2019 and 2022 that were …
20y · Male·hypoxic encephalopathy
Matthew Lynn, aged 20, died from hypoxic encephalopathy after sustaining head injuries in a motor vehicle collision. While hospitalised in ICU, his endotracheal tube (ETT) became displaced around 12:20am on 23 January 20…
Female·Judith Lesley Ward died as a result of Thermal Injury; Lorraine Melia died as a …
…aths were preventable and arose through misadventure. The inquest identified systemic failures including inadequate records, poor communication between management and field staff, lack of conductor monitoring, and Wester…
40y · Male·Ligature compression of the neck in circumstances of being hanged
Adam Omerovic, a 40-year-old man with a long history of depression, substance abuse, and prior suicide attempts, died by hanging in a Melbourne Assessment Prison cell on 23 March 2010. He had been remanded on armed robbe…
57y · Male·Severe coronary artery disease. It is likely that Kevin's use of inhalants in cu…
…rrectional Centre. The coroner found the care received for his chronic inhalant use disorder was grossly inadequate. Clinical lessons include: (1) abnormal ECG results require timely specialist review and follow-up, not …
22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…
Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…
36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…
Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He was administered multiple s…
2y · Male·Group A Streptococcal toxic shock syndrome which probably originated in the thro…
Ryan Saunders, a 2-year-old boy, died from Group A Streptococcal toxic shock syndrome after a 72-hour presentation with fever, pain, and systemic illness. Initial GP care was appropriate given the presentation and diagno…
Male·neck compression due to hanging
Two men died by suicide within five months of emergency department assessments at Lyell McEwin Hospital. Both had been brought in by police under Mental Health Act section 57 but were not detained and discharged after mi…
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