2,017
Total cases
65%
Preventable or possibly preventable
66%
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.
64y · Male·Complications of Alzheimer's dementia
Allan Anton, aged 64, died on 24 September 2025 from complications of Alzheimer's dementia at his specialist disability accommodation in Tarneit. He was diagnosed with younger onset dementia in November 2021 following a …
33y · Female·Combined drug toxicity (heroin, benzodiazepines, methylamphetamine, mirtazapine,…
BP, a 33-year-old female with longstanding opioid and polysubstance use disorder, died from accidental heroin overdose at home with concomitant CNS depressants (benzodiazepines, mirtazapine, promethazine) and stimulant (…
64y · Female·Presumed massive pulmonary embolus
Mrs Keating, aged 64, presented to University Hospital Geelong ED with a two-day history of shortness of breath and cough, with known history of pulmonary embolism. Attending physicians appropriately considered PE as dif…
74y · Male·Pulmonary thromboembolism due to right deep vein thrombosis
Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond t…
84y · Male·bronchopneumonia complicating C2 odontoid fracture (palliated) due to fall on a …
Wayne Malcolm Clark, aged 84, with advanced Alzheimer's and vascular dementia, fell in a secure residential aged care facility and sustained a C2 odontoid fracture. He died on 23 August 2023 from bronchopneumonia complic…
91y · Female·Aspiration pneumonia in a woman with multiple co-morbidities
91-year-old woman with disability living in specialist disability accommodation who died from aspiration pneumonia. She had documented moderate oropharyngeal dysphagia from prior stroke, managed with pureed diet and thic…