268
Total cases
44%
Preventable or possibly preventable
54%
With coroner recommendations
33%
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…
87y · Female·Oesophageal perforation following an elective oesophageal dilatation, secondary …
87-year-old Helen Mahlis died from oesophageal perforation following an elective balloon dilation procedure at Epworth Richmond for treatment of achalasia. The coroner identified two contributing factors: use of a 35mm b…
69y · Male·peritonitis due to perforated bowel
Mr Deleman was a 69-year-old man with untreated schizophrenia, advanced liver cirrhosis, and hepatitis C, presenting to hospital on 1 April 2024 with abdominal swelling. He was admitted to The Canberra Hospital and place…
85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …
An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …
56y · Male·complications of viral hepatitis related advanced-chronic liver disease
Russell Graham Penny, 56, a Noongar man, died from advanced liver disease with hepatocellular carcinoma while in prison custody. With chronic hepatitis C from intravenous drug use, Russell had developed cirrhosis and was…
41y · Male·Acute liver failure with contributing Castleman's disease
A 41-year-old Aboriginal man with HIV and Castleman's disease died from acute liver failure while on home detention. He had variable compliance with antiretroviral therapy, exacerbated by amphetamine use disorder and men…