816
Total cases
35%
Preventable or possibly preventable
40%
With coroner recommendations
23%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
75y · Male·Complications of an out of hospital cardiac arrest secondary to anaphylaxis trig…
A 75-year-old man died from anaphylaxis triggered by self-administered peptide injections (CJC1295/Ipamorelin), which he was taking in excess of the prescribed dose. He injected a dose at home on 28 March 2025, collapsed…
66y · Male·haemoptysis from a cavitated lesion of the left lung with aspergillus and candid…
A 66-year-old man serving a life sentence at Yatala Labour Prison died from haemoptysis caused by a cavitated lung lesion with aspergillus and candida infection. He had multiple chronic comorbidities including ischemic h…
67y · Female·Multisystem failure complicating urosepsis and acute myeloid leukaemia
A 67-year-old woman with intellectual disability living in specialist disability accommodation was diagnosed with Acute Myeloid Leukaemia in May 2024 and received low-intensity chemotherapy at home. In July 2024, she was…
62y · Female·Pneumonia in a woman with cerebral palsy (palliated)
Amanda Lee Turner, 62 years old with cerebral palsy and mild intellectual disability, died from pneumonia on 3 July 2023 at Benalla Health. She had a PEG feeding tube inserted in January 2023 after developing dysphagia (…
62y · Male·Alzheimer's disease
Stewart Barclay, a 62-year-old man with Alzheimer's disease diagnosed in 2015, died from natural causes at McCulloch House palliative care unit on 16 November 2025. He had been living in NDIS-funded disability accommodat…
67y · Male·glioblastoma of the central brain
Russell Longmore, a 67-year-old Aboriginal man with schizophrenia on involuntary mental health treatment, was hospitalized in February 2025 after a fall that revealed a malignant brain tumour (glioblastoma). When neurosu…