306
Total cases
79%
Preventable or possibly preventable
77%
With coroner recommendations
42%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
37y · Male·Neck compression and the complications thereof
Simon Mackay, age 37, was admitted as an involuntary psychiatric patient on 12 July 2022 for acute methamphetamine-induced psychosis with paranoia and aggression, complicated by severe polysubstance dependence. Although …
29y · Male·Cardiac arrhythmia in the context of alcohol withdrawal and chronic alcohol misu…
A 29-year-old man died from cardiac arrhythmia in the context of severe alcohol withdrawal at a correctional facility. Initial assessment correctly identified moderate-to-severe withdrawal (AWS score 8) with seizure hist…
Male, female, male, female·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …
Joint inquest into four deaths of individuals prescribed opioid replacement therapy by Dr J. between September 2016 and August 2017: Nicholas Shane Brown (35), Toni Lee Wiki (38), Matthew Wayne Winwood (47), and Belinda …
32y · Male·multiple injuries caused by a single vehicle crash
A 32-year-old man with long-standing methamphetamine addiction and drug-induced psychosis died in a motor vehicle crash on 6 January 2024. Although he received hospital treatment for severe psychosis in August 2023 and w…
50y · Male·unascertained
Simon Gaskill, aged 50, was found deceased in sand dunes at Ocean Grove Beach in April 2022 after sleeping rough for months. He had been discharged from hospital in December 2021 following treatment for severe alcohol wi…
25y · Male·Combined drug toxicity
Harrison William Ladd, 25, died from combined drug toxicity involving clonazepam, dexamphetamine, codeine, diazepam and pholcodine. He had complex mental health and substance use disorder requiring specialist addiction c…