219
Total cases
65%
Preventable or possibly preventable
68%
With coroner recommendations
50%
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·Colonic adenocarcinoma and its treatment
Jeffrey Olsen, 64, died from acute capecitabine toxicity during adjuvant chemotherapy for Stage 3b colorectal cancer. Within three days of commencing treatment in September 2020, severe side effects including diarrhea, r…
87y · Female·Oesophageal perforation following an elective oesophageal dilatation, secondary …
87-year-old Helen Mahlis died from oesophageal perforation following an elective balloon dilation procedure at Epworth Richmond for treatment of achalasia. The coroner identified two contributing factors: use of a 35mm b…
71y · Male·metastatic papillary renal cell carcinoma
Robert Bell-Williams, aged 71, died from metastatic papillary renal cell carcinoma while in lawful custody at Long Bay Hospital on 1 February 2024. Imprisoned since 2012, he was diagnosed with renal cell carcinoma in 202…
71y · Male·Multiple injuries sustained in motorcycle crash
Damian Brian Thompson, aged 71, crashed his motorcycle on a rural road in Tasmania during torrential rain, sustaining severe injuries to his left leg and left hand. He was transported to Launceston General Hospital where…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…
78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …
A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…