905 results for “inadequate supervision”
16y · Male·Peritonitis as a result of ruptured duodenum following blunt trauma of the torso
…ailures: diagnostic error (missing internal abdominal injury), failure to escalate to senior clinicians, inadequate examination technique (in a wheelchair), poor handover and documentation, and lack of proper discharge i…
2y · Female·irreversible cerebral anoxia and terminal inhalation bronchopneumonia resulting …
…d at the pool while going to the toilet, unrealistically expecting another visitor to supervise; and (2) inadequate lifeguard supervision—lifeguards were distracted with slide supervision and other duties and did not det…
2y · Male·Drowning
…ile his mother was distracted by her mobile phone, despite being only two metres away. The coroner found inadequate supervision was the critical factor. Key clinical lessons: drowning can occur in seconds with minimal st…
92y · Male·Head and neck injuries sustained in a fall in a man with multiple co-morbidities
…h, he was left unsupervised during afternoon tea in the dining room despite being assessed as requiring supervision during mealtimes and assistance to mobilise. He left the dining room undetected without his walker and …
4y · Unknown·Drowning
…st initially, he removed it to use water slides more freely. While approximately 8 adults were present, supervision was inadequate and divided—his father was watching a 2-year-old sibling in a separate toddler pool whil…
Female·Drowning
…ificate. The family had a prior child protection history involving domestic violence and concerns about supervision. Key preventability factors included: inadequate parental supervision, failure to maintain pool safety …
2y · Unknown·Drowning in swimming pool
…iance issues with fencing clearance zones, the primary failure was the open gate. The coroner identified inadequate adult supervision and non-compliant pool safety gates (particularly those held open) as the greatest ris…
4y · Male·Drowning
…ally but removed it to use water slides more freely. While approximately 20 people attended (8 adults), supervision was inadequate—his father was watching a 2-year-old sibling in a separate toddler pool and his mother w…
0y · Male·drowning
…m from the bath base, Christopher became trapped with his head unable to surface. The coroner identified inadequate supervision as the critical factor, noting the mother was distracted by a 10-20 minute phone call withou…
0y · Female·Mechanical asphyxia due to or as a consequence of overlaying while bed-sharing d…
… Zelia, was exhausted after labour and fell asleep while breastfeeding Bela lying down without adequate supervision. Critical failures included: inadequate patient education about the dangers of falling asleep while bre…
48y · Male·drowning
… was left in a busy, noisy shared waiting room with only administrative staff awareness of his need for supervision. Clinical staff checked on him intermittently but no direct observation occurred. He left saying he nee…
83y · Female·Complications arising from a fall with C2 fracture and neck of femur fracture
…ing room for approximately 7 minutes during mealtimes, contrary to facility policy requiring continuous supervision. The resident stood and walked unobserved to an adjoining lounge area where she lost balance and fell, …
64y · Male·stab wound to the chest
…systemic failures in the adult parole system contributed to this preventable death. Key issues included: inadequate drug testing despite Perry's drug history, failure to detect his substance abuse despite specialist paro…
0y · Male·Hypoxic ischaemic encephalopathy due to an out of hospital cardiac arrest second…
A 10-month-old boy drowned in a backyard fishpond after a 27-minute period of inadequate supervision. He was found unresponsive by his aunt and underwent prolonged resuscitation, suffering seve…
49y · Male·multiple injuries
…d voluntarily offered to guide the truck as it reversed in a confined space. Critical failures included: inadequate supervision and training of the truck driver (VSO Grocott), who had minimal heavy vehicle experience and…
19y · Male·Hypoxic brain injury due to aspiration of food bolus
…n of a food bolus while in disability respite care. Critical failures included: reduction of one-to-one supervision around meal times 6 months prior without formal documentation or family consultation, despite his known…
24y · Male·Peritonitis secondary to a perforation of the small bowel
…conservative management without close monitoring or surgical review. Critical failures included: Dr K.'s inadequate management plan lacking surgical follow-up; failure to escalate to the surgical consultant Dr K. despite…
44y · Male·Strangulation
…gement. Considine was subject to a Community Corrections Order (CCO) for theft and burglary but received inadequate supervision despite being assessed as high-risk. Key failures included: incorrect initial risk assessmen…
9y · Female·Head injury (basilar skull fractures) from collapse of central support pole
…he death arose by misadventure but identified systemic failures in building regulation and construction supervision. Multiple defects were identified: omissions in structural plans, inadequate specification of critical …
57y · Female·Ischaemic heart disease
…n and she died. Critical systemic failures: the facility had no smoking policy for vulnerable residents, inadequate supervision protocols, and staff could not explain how she accessed cigarettes or the secured courtyard.…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.