446
Total cases
74%
Preventable or possibly preventable
84%
With coroner recommendations
56%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
48y · Male·Pulmonary thromboembolism
Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…
62y · Male·multi-organ failure on a background of aortic regurgitation and ischaemic heart …
A 62-year-old man with aortic regurgitation and coronary artery disease died from multi-organ failure after emergency cardiothoracic surgery. His elective surgery was cancelled twice (14 and 22 Aug 2023) due to prioritiz…
34y · Male·95% total body surface area burns and inhalational injury sustained in a vehicle…
TE, a 34-year-old male, died on 22 February 2024 from 95% total body surface area burns and inhalational injury sustained in a deliberate vehicle fire on the Monash Freeway. The coroner confirmed this was suicide, noting…
<1y · Male·traumatic head injury due to instrumental vaginal delivery of a term infant
Baby H died on 24 March 2019, one day after birth, from traumatic head injuries sustained during an instrumental vaginal delivery using Neville Barnes forceps on a baby in occipito-posterior position. Critical clinical l…
62y · Female·Acute bacterial peritonitis and pneumonia
Rosemarie Campbell, 62, died 27 February 2022 from acute bacterial peritonitis and pneumonia following a Roux-en-Y gastric bypass at Wesley Hospital. Pre-operative failures: The surgeon inadequately investigated her refl…
55y · Male·Unascertained
A 55-year-old man with known HIV infection, who was homeless and vulnerable, was found unconscious in a hot bath at a friend's home in South Yarra and rapidly transported to hospital. He presented with profound shock, hy…