131
Total cases
57%
Preventable or possibly preventable
69%
With coroner recommendations
36%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
49y · Female·Coronary artery atherosclerosis in the setting of pulmonary valve replacement fo…
Carol Rae Street, age 49, died at Royal Melbourne Hospital on 13 September 2025, three days after undergoing percutaneous pulmonary valve insertion for pulmonary regurgitation related to tetralogy of fallot. She was foun…
85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …
An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …
Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…
Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…
73y · Male·Gregory Frank Burkhalter: carbon monoxide toxicity due to inhalation of carbon m…
Two elderly US-born residents died in a house fire caused by a 120-volt electric blanket operating on Australia's 230-volt grid, resulting in insulation failure and combustion. Mr Burkhalter (73) died from carbon monoxid…
67y · Male·Type 2 respiratory failure due to pneumonia
Dennis Jackson, a 67-year-old from Broken Hill, underwent left upper lobe lobectomy based on a falsely positive lung biopsy contaminated with squamous cell carcinoma tissue from another patient during processing at SA Pa…
48y · Male·gunshot wound to chest
Peter Owen Pilkington, 48, died from a gunshot wound sustained during a police siege on 6 December 2021. After escalating behaviour at his NDIS support office in Stretton, Queensland, Peter produced what police believed …