762
Total cases
36%
Preventable or possibly preventable
42%
With coroner recommendations
24%
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…
92y · Male·respiratory failure secondary to bilateral pleural effusions on a background of …
Hans Biermann, aged 92, died on 1 March 2023 following respiratory failure secondary to bilateral pleural effusions and rib fractures sustained in a fall at Regis Playford aged care facility on 23 February 2023. Mr Bierm…
63y · Female·1a: Aspiration pneumonia in a woman with acquired brain injury, 1b: Cerebrovascu…
Susan Czudar, 63, died of aspiration pneumonia complicated by acquired brain injury from a 2017 subarachnoid haemorrhage and multiple strokes. Residing in NDIS-funded specialist disability accommodation, she was admitted…
32y · Female·cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage
Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. mis…
57y · Female·Urosepsis due to an obstructing renal calculus in a woman with multiple comorbid…
Christine Giliberto, aged 57, died of urosepsis from an obstructing kidney stone. She lived in supported disability accommodation with severe lifelong disabilities (hydrocephalus, cerebral palsy, non-verbal). An obstruct…
50y · Female·Intracranial haemorrhage (left frontoparietal intraparenchymal haemorrhage with …
Janene Louise Weston, a 50-year-old woman with acquired brain injury from autoimmune encephalitis and history of multiple strokes, died at home in specialist disability accommodation from an intracranial haemorrhage. She…