3,823
Total cases
62%
Preventable or possibly preventable
67%
With coroner recommendations
38%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
75y · Male·Complications of an out of hospital cardiac arrest secondary to anaphylaxis trig…
A 75-year-old man died from anaphylaxis triggered by self-administered peptide injections (CJC1295/Ipamorelin), which he was taking in excess of the prescribed dose. He injected a dose at home on 28 March 2025, collapsed…
34y · Male·Hanging (suicide by ligature)
Justin Cordy, a 34-year-old man, died by suicide via hanging in the Alexander Maconochie Centre (AMC) prison on 26 February 2023 while on remand. The coroner found multiple critical system failures contributed to his dea…
45y · Male·Suicide by hanging
45-year-old Aboriginal man with schizophrenia presented to ED after wrist-cutting attempt. Police apprehended him and admitted as involuntary mental health patient under Form 9 requiring psychiatric assessment, but absco…
90y · Female·Aspiration pneumonia secondary to choking, on a background of Alzheimer's dement…
Maria Kalompratsos, aged 90, died from aspiration pneumonia following a choking incident at St Basil's aged care facility. She had advanced Alzheimer's dementia with mild oropharyngeal dysphagia, appropriately managed th…
66y · Male·haemoptysis from a cavitated lesion of the left lung with aspergillus and candid…
A 66-year-old man serving a life sentence at Yatala Labour Prison died from haemoptysis caused by a cavitated lung lesion with aspergillus and candida infection. He had multiple chronic comorbidities including ischemic h…
<1y · Male·unascertained
JB, an 8-week-old infant, died unexpectedly at home on 8 April 2022. No definitive cause of death could be determined despite comprehensive autopsy investigations and medical review. Concerning findings included multiple…