905 results for “inadequate supervision”
55y · Male·Hanging
Peter Tully, 55, died by hanging 4 days after discharge from his first psychiatric admission for major depressive disorder with suicidality. He had made 3 suicide attempts in the week before admission. During hospitalisa…
Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…
…lue of early intervention and proactive community-based assessment rather than reactive crisis response; inadequate assessment of suicidal ideation (no thorough exploration of methods discussed); and the need for clear p…
Male·multiple injuries sustained in motorcycle crash
Dennis Green, a First Class Constable with WA Police, died on 7 December 2017 while undertaking a motorcycle training course on Julimar Road, Toodyay. His motorcycle crashed on a rural bend during a P1 (high-speed) devel…
30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…
Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …
asphyxia sequential to hanging (all three cases); Charles Barlow: schizophrenia …
…spital to die by suicide hours later. Patrick Lusk (66) was admitted with severe depression but received inadequate mental state and risk assessment; discharged after 48 hours without proper mental health referral and di…
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