233
Total cases
63%
Preventable or possibly preventable
66%
With coroner recommendations
49%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
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 …
64y · Male·Peritonitis and ischaemic small bowel, with contributing factors of hypertensive…
A 64-year-old male with hypertension and smoking history presented to hospital with several weeks of abdominal pain, diarrhoea, and weight loss. Imaging revealed a superior mesenteric artery (SMA) occlusion deemed chroni…
49y · Female·Acute pancreatitis
Linda Anne Bullen, a 49-year-old woman with Down syndrome and multiple comorbidities including dysphagia, rheumatoid arthritis, and vision impairment, died from acute necrotising pancreatitis complicated by aspiration pn…
67y · Male·Complications of chronic bowel obstruction; marked faecal loading in a man with …
Mark Ronald Blyth, aged 67, had severe intellectual disability with significant comorbidities including epilepsy, dysphagia, and chronic aspiration risk. He died from complications of chronic bowel obstruction with marke…
48y · Male·Pulmonary thromboembolism
Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…
64y · Male·Multiorgan dysfunction and progressive failure following complications of severe…
William John Dick, a 64-year-old man with multiple comorbidities including diabetes, hypertension, obesity, atrial fibrillation and autism, sustained severe thermal burns (47.5% body surface area) when playing with fire …