271
Total cases
44%
Preventable or possibly preventable
53%
With coroner recommendations
32%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
52y · Male·perforation of a hollow viscus complicating oesophageal cancer in a man with cer…
Adam Barry, a 52-year-old man with cerebral palsy, dysphagia, and epilepsy, was diagnosed with metastatic oesophageal cancer in February 2024 after presenting to hospital with vomiting. Living in Specialist Disability Ac…
66y · Female·Acute oesophagitis complicated by gastrointestinal haemorrhage
A 66-year-old woman with cerebral palsy, dysphagia, and chronic reflux oesophagitis presented with acute gastrointestinal bleeding while in supported disability accommodation. She was treated conservatively with IV proto…
64y · Female·Hepatocellular carcinoma
Susan McFarlane, 64, died on 29 July 2025 from hepatocellular carcinoma with cirrhosis as a contributing factor. She was an NDIS participant living in specialist disability accommodation with daily support. In June 2025,…
51y · Male·Complications of stage 4 hepatocellular carcinoma
Phillip Graeme Abell, aged 51, died from stage 4 hepatocellular carcinoma (HCC) with underlying cirrhosis and hepatitis C infection. Imprisoned at Woodford Correctional Centre, Mr Abell was diagnosed with infiltrative HC…
67y · Male·Multi-organ failure secondary to acute myocardial infarction secondary to in-ste…
Christopher Doughty, 67, was admitted to Hervey Bay Hospital on 17 September 2021 with a life-threatening gastrointestinal bleed two months after receiving coronary stents. The bleed was likely caused by dual antiplatele…
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…