VIChome2005-02-11
AYRE Gordon
Male·Drowning
… awareness campaign by Life Saving Victoria focused on rural water safety, child-safe play areas, carer supervision education, and collaboration with farming organizations.
905 results for “inadequate supervision”
Export CSV (905)
WAhome2021-04-16
Inquest into the Death of Child LDW (Name Subject to Suppression Order)
3y · Female·tramadol toxicity
…itoring rather than prolonged unsupervised sleep; and vulnerable children in care require more frequent supervision and welfare checks. The Department's case management failed to escalate concerns about the carer's dete…
paediatricsforensic medicinesystemdelaytramadol
VIChome2013-10-01
Finding into death of Dion Heather
38y · Male·Aspiration of Gastric Content and Combined Drug Toxicity (Methadone, Benzodiazep…
…The coroner identified a critical systemic issue: take-away methadone doses were dispensed with minimal supervision despite being Schedule 8 drugs. The deceased had previously required multiple resuscitations within two…
addiction medicinegeneral practicesystemdelaymethadone
VICaged care2022-09-02
Finding into death of Alan Joseph Wilson
55y · Male·Acute alcohol toxicity
…reased significantly and mental health deteriorated. Staff implemented an alcohol consumption plan with supervision, but Wilson was non-compliant and continued smuggling alcohol into the facility. In the weeks before de…
geriatric medicinepsychiatrysystemalcohol
SAmental health2009-12-04
Coroner's Finding: BLUNDEN Peter Ross
54y · Male·hanging by ligature
…oncerning statements made to a junior doctor (Dr Y.) on the day of death to senior psychiatry staff; (2) inadequate supervision despite persistent suicidal ideation—he remained in open ward with only hourly sightings and…
psychiatryemergency medicinecommunicationsystemoxazepam
VIC2013-10-02
Finding into death of Daniel Tyson Pelka
19y · Male·aspiration of latex glove; intellectual disability
…his mouth and required high-level support (level 5). Despite staff awareness of this risk, insufficient supervision was provided and choking hazards (latex gloves) were inadequately secured. Gloves were stored in access…
emergency medicinesystemcommunication
WAcommunity2002-12-20
Inquest into the Death of Lauren Jay Kitching
5y · Female·Head and neck injuries sustained in collision with utility vehicle while operati…
…e was participating in a holiday program fun kart activity run by the Shire of East Pilbara with police supervision. After being asked if she could drive alone and responding confidently, the deceased accelerated the ka…
diagnosticsystem
TAS2021-08-09
Coroner's Finding: Negga, Retbe Chide
50y · Male·blunt trauma of the abdomen, pelvis and legs
…o board a moving tractor-trailer at a cherry orchard. Key clinical and occupational lessons include: (1) inadequate safety induction that failed to account for linguistic barriers—employees could not fully comprehend ins…
trauma surgeryemergency medicinesystemcommunicationketamine
TASaged care2016-12-19
Coroner's Finding: Cobham, David Alexander
84y · Male·aspiration pneumonia following rhabdomyolysis due to entrapment of his right arm…
… The coroner found the death was preventable had the documented care plan been implemented and adequate supervision provided. Key clinical lessons: communication of care plans to all staff is essential, monitoring syste…
geriatric medicinegeneral medicinecommunicationsystem
ACThome2003-12-23
Inquest Into The Manner And Cause Of Death Of Neil Summerell
34y · Male·extensive blood loss from acute gastric erosions following severe scalding of th…
… this being routine in specialist burns units; (3) significant failures in disability services including inadequate carer training, no reading of individual care plans despite industry standards, poor handovers, and lack…
emergency medicinegeneral practicesystemcommunication
TASaged care2023-01-30
Coroner's Finding: Munnings, Barry
86y · Male·pneumonia
…l fracture. He was assessed as medium falls risk despite risk-taking behaviours and non-compliance with supervision. Discharged from hospital with pain relief and physiotherapy, his condition deteriorated within 24 hour…
geriatric medicineemergency medicinediagnosticsystem
QLDhome; home; home2013-07-04
Fuller, Matthew James; Barnes, Rueben Kelly; Sweeney, Mitchell Scott
25; 16; 22y · Male; male; male·Electrocution; Electrocution; Electrocution
…similarly to Matthew when a metal staple pierced a live cable. The coroner identified critical failures: inadequate training (especially on electrical hazards), absent or ineffective supervision, reliance on untrained wo…
communicationsystem
VIC2014-10-07
Finding into death of Darren Carr Hannah
41y · Male·Upper airway obstruction from ingestion of dirt in an intellectually impaired ma…
…azards (dirt, soil) should be actively removed or minimised; (3) staffing levels must ensure continuous supervision during meal breaks—having only one staff member present created a supervision gap when the other was on…
general practicepsychiatrysystemsupervisiondiazepam
NSWcommunity2011-03-11
Coroner's Finding: Shayne Hamilton McMahon
20y · Male·Widespread hypoxic brain injury secondary to cardiac arrhythmia, ventricular fib…
…ised to break into a live gas line in a ring main system—a complex task requiring licensed tradesperson supervision. Critical safety failures included: no supervision by his licensed employer, incomplete training (prior…
emergency medicineintensive careproceduralsystem
SAaged care2020-02-28
Coroner's Finding: NISCO Sophia Alessia
16y · Female·upper airway occlusion due to aspiration of a foreign body (disposable latex glo…
…ity, in bins, and dispensers) and aspirated one, leading to fatal airway obstruction. The coroner found supervision was inadequate, care plans were insufficient in identifying and communicating risks, and there was a st…
rehabilitation medicinesupervisionsystem
SAcommunity2009-06-30
Coroner's Finding: SALAGARAS Steven
56y · Male·effects of heat exhaustion
…ed kidney scarring, which may have exacerbated heat effects. He had an nearly empty water bottle and was inadequately dressed for extreme conditions. The coroner found that although the employer had advised against worki…
occupational and environmental healthforensic medicinesystemdelay
WAhome2021-08-10
Inquest into the Death of Scott William MARTIN
40y · Male·Penetrating wounds to the chest
…ttending officers lacked critical safety information about the knife brandished at the earlier address. Supervision of junior constables during the initial investigation was inadequate. Whilst the decision to release fr…
emergency medicinepsychiatrycommunicationsystemmethamphetamine
NThome2022-06-10
Inquest into the death of Roberta Curry
28y · Female·hypovolaemia due to spleen laceration due to blunt force trauma to the torso
…ined unaware of her reports or his breaches; failed random breath testing attempts went unaddressed; and inadequate community corrections supervision during the high-risk early post-release period. Had police properly in…
emergency medicineforensic medicinecommunicationsystem
NSWhome2018-03-27
Inquest into the death of Braxton Slager
1y · Male·Drowning
…the carer (Julie Tarlinton) lacked emotional capacity after losing a long-term foster child and received inadequate support from the agency (Life Without Barriers). The home environment was unsafe, with an non-compliant …
systemcommunicationcyproheptadine
NTpolice custody2010-05-19
Inquest into the death of Cedric Trigger
32y · Male·traumatic subdural haemorrhage resulting from blunt head trauma
…h house keeper despite policy requirements, failure to escalate concerns about his non-responsive state, inadequate supervision of very junior staff, and poor communication between arresting officers and security guards …
emergency medicineneurosurgerydiagnosticcommunication
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