1,981
Total cases
65%
Preventable or possibly preventable
66%
With coroner recommendations
42%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
41y · Female·Injuries sustained in a fall from a height
VNP was a 41-year-old woman with longstanding bipolar disorder type 1, chronic pain from endometriosis, and substance misuse history who died by suicide on 10 July 2023. She had experienced homelessness, family estrangem…
0y · Male·traumatic head injury due to instrumental vaginal delivery of a term infant
Baby H died on 24 March 2019, one day after birth, from traumatic head injuries sustained during an instrumental vaginal delivery using Neville Barnes forceps on a baby in occipito-posterior position. Critical clinical l…
43y · Male·Aspiration of food bolus
FVH, aged 43, died from aspiration of a food bolus while dining at a restaurant on 1 November 2025. FVH had Astrom Syndrome, a lifelong condition causing deafness and blindness from retinitis pigmentosa, as well as insul…
61y · Female·Unascertained (natural causes)
Ms Harris, aged 61, with intellectual disability, autism spectrum disorder, and multiple medical conditions (including aortic regurgitation, hypothyroidism, dyspnoea, hyperlipidaemia, and obesity), was living in supporte…
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…
[77, 80, 55]y · ["female", "male", "female"]·Multiple injuries from motor vehicle collision
A motor vehicle collision on the Princes Highway near Suttontown killed three adults when a 16-year-old driver with significant neurological conditions momentarily lost concentration while ascending a hill. The driver ha…