2,060
Total cases
64%
Preventable or possibly preventable
65%
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.
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…
Male·combined effects of cardiomyopathy and metastatic melanoma
Geoffrey Croft, imprisoned in New South Wales, developed melanoma diagnosed late during custodial care. He first noticed a lesion on his back in October 2019 but wasn't examined medically until March 2020 (when bleeding …
61y · Female·chronic obstructive pulmonary disease and myocardial fibrosis, in the setting of…
A 61-year-old Aboriginal woman with multiple chronic conditions (COPD, myocardial fibrosis, alcoholic cirrhosis, dementia) died in aged care following a fall from bed. During COVID-related staffing shortage, an enrolled …
<1y · Male·unascertained
JB, an 8-week-old infant, died unexpectedly at home on 8 April 2022. No definitive cause of death could be determined despite comprehensive autopsy investigations and medical review. Concerning findings included multiple…
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 (…
<1y · Female·Sudden unexpected death of a small for gestational age infant (SUDI), accidental…
A 3-day-old Aboriginal newborn died from accidental asphyxiation while co-sleeping with her exhausted mother in a hospital bed following emergency Caesarean section. The infant was small for gestational age with birth-re…