454
Total cases
73%
Preventable or possibly preventable
83%
With coroner recommendations
55%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
<1y · Male·Hypoxic-ischaemic encephalopathy caused by sudden and profound fetal bradycardia
Hugo Alexander McGregor was born on 11 March 2023 following emergency caesarean section at Mackay Base Hospital after sudden fetal bradycardia during labour. His mother's labour was induced with Syntocinon at 15:00 hours…
Male·pulmonary thromboembolism secondary to deep vein thrombosis of the right calf fo…
Kenneth Toll died from pulmonary embolism secondary to deep vein thrombosis on day four after bilateral knee replacement surgery at Albury Wodonga Private Hospital. While the surgery itself was appropriate and well-perfo…
59y · Female·Complications following a right total hip replacement for severe osteoarthritis …
Anne Margaret Chase, aged 59, had Down syndrome, dementia, and severe bilateral osteoarthritis. Despite previous medical advice against surgery, her severe hip pain and immobility led to right total hip replacement at Mu…
89y · Female·Complications following a fall (long lie, rib fractures and iatrogenic pneumotho…
An 89-year-old frail woman with dementia, COPD, and osteoporosis fell at her aged care facility and waited over 5 hours for ambulance response due to St John NT capacity shortages. A forensic pathologist concluded this p…
3y · Male·Sepsis caused by mixed bacterial and viral pathogens including Streptococcus pne…
Kumanjayi Johnson, a 3-year-old Aboriginal child with cerebral palsy, hydrocephalus, and developmental delay from prematurity, died of sepsis in June 2024 while in state care. On 3 June, his carer obtained a telehealth G…
6y · Male·Hypoxic-ischaemic encephalopathy due to cardiac arrest following general anaesth…
Connor Dean, a 6-year-old with Down syndrome, died following cardiac arrest during an MRI under general anaesthetic. He had severe vitamin C deficiency (scurvy) which was not detected despite clinical and nutritional ris…