3,790
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.
78y · Female·Multiple organ failure secondary to sepsis and renal failure due to bronchopneum…
A 78-year-old woman with cognitive impairment, depression, and complex care needs fell at home on 11 February 2022. Her sons delayed seeking medical help for 4 days, during which she developed aspiration pneumonia and wa…
33y · Female·Combined drug toxicity (heroin, benzodiazepines, methylamphetamine, mirtazapine,…
BP, a 33-year-old female with longstanding opioid and polysubstance use disorder, died from accidental heroin overdose at home with concomitant CNS depressants (benzodiazepines, mirtazapine, promethazine) and stimulant (…
78y · Male·Complications of acute renal impairment in the setting of pelvic and lumbar frac…
Garry Ledger, 78-year-old South Australian visitor, died three weeks after falling on a Melbourne tram on 28 August 2025. While boarding tram route 16, he fell during tram acceleration while using his Myki card and befor…
64y · Female·Presumed massive pulmonary embolus
Mrs Keating, aged 64, presented to University Hospital Geelong ED with a two-day history of shortness of breath and cough, with known history of pulmonary embolism. Attending physicians appropriately considered PE as dif…
74y · Male·Pulmonary thromboembolism due to right deep vein thrombosis
Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond t…
75y · Male·combined effects of subdural haematoma and facial fractures following a fall com…
A 75-year-old man with advanced Alzheimer's dementia residing in aged care died in hospital following a fall at his residential facility. He was assessed as high falls risk at the aged care facility. After collapsing and…