86
Total cases
63%
Preventable or possibly preventable
69%
With coroner recommendations
41%
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·Hypernatraemia in the setting of lowered oral intake
Kerrie Berlowitz, 78, with cerebral palsy and intellectual disability, died of hypernatraemia (severe sodium elevation) due to dehydration. Living in supported disability accommodation in Carrum, she progressively refuse…
49y · Male·Diabetes Mellitus and the Consequences thereof
Mr Edward Curic (49) died at Long Bay Correctional Complex on 21 May 2022 from diabetes mellitus and complications. He had poorly controlled Type 2 diabetes for 30 years with severe complications including bilateral ampu…
29y · Male·Ketoacidosis as a consequence of diabetes mellitus (Type 1)
Steven Thelander, aged 29, died from ketoacidosis due to poorly controlled Type 1 diabetes while in residential disability support care at Multicap. He had cerebral palsy with severe intellectual impairment and epilepsy …
38y · Male·Diabetic ketoacidosis secondary to pyelonephritis in a man with insulin dependen…
A 38-year-old man with insulin-dependent diabetes, partial blindness, gastroparesis, seizures, chronic kidney disease and peripheral vascular disease died from diabetic ketoacidosis precipitated by pyelonephritis. He had…
81y · Male·COVID-19 infection on a background of Type 2 Diabetes and end stage chronic kidn…
Robert Sievers, an 81-year-old man incarcerated since 2001, died from COVID-19 infection on a background of type 2 diabetes and end-stage chronic kidney disease. Despite multiple warnings about vaccination, Sievers refus…
45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia
A 45-year-old Aboriginal man with poorly managed diabetes and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs i…