63
Total cases
63%
Preventable or possibly preventable
63%
With coroner recommendations
52%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
37y · Female·sepsis secondary to rectosigmoid perforation on a background of metastatic squam…
Carmen Jayne Clancy, aged 37, died on 27 September 2022 from sepsis secondary to rectosigmoid perforation caused by metastatic cervical cancer. Incarcerated on home detention following a cancer diagnosis in 2021, she und…
64y · Male·Complications of advanced rectal carcinoma
David Ronald Thompson, a 64-year-old man with severe intellectual disability and complex medical needs, died from complications of advanced rectal carcinoma. He resided in specialist disability accommodation and had been…
82y · Male·Complications of large bowel obstruction in a man with diverticular disease and …
An 82-year-old man died from complications of large bowel obstruction secondary to a sigmoid mass while incarcerated at Port Phillip Prison. He presented with abdominal pain and vomiting following a fall, and imaging con…
65y · Male·metastatic rectal cancer with extensive lung metastases
A 65-year-old man died from metastatic rectal cancer with extensive lung metastases while serving a prison sentence. He had presented with rectal bleeding symptoms since 2011 and returned a positive faecal occult blood t…
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
74y · Male·Sepsis secondary to fistulating Crohn's disease and post-surgery complications f…
Christopher Essery, a 74-year-old man with complex fistulating Crohn's disease, died from sepsis following surgery on 24 January 2019. He was transferred to Princess Alexandra Hospital (PAH) on 31 August 2018 for special…