687
Total cases
44%
Preventable or possibly preventable
46%
With coroner recommendations
28%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
90y · Female·Aspiration pneumonia secondary to choking, on a background of Alzheimer's dement…
Maria Kalompratsos, aged 90, died from aspiration pneumonia following a choking incident at St Basil's aged care facility. She had advanced Alzheimer's dementia with mild oropharyngeal dysphagia, appropriately managed th…
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 …
62y · Male·Alzheimer's disease
Stewart Barclay, a 62-year-old man with Alzheimer's disease diagnosed in 2015, died from natural causes at McCulloch House palliative care unit on 16 November 2025. He had been living in NDIS-funded disability accommodat…
67y · Male·Bronchopneumonia in the setting of drug-induced Parkinson's disease, hypoxic bra…
Glen Rowan Bailey, aged 67, died of bronchopneumonia at Bendigo Health Hospice after complex psychiatric and medical management. Resident in specialist disability accommodation with lifelong intellectual disability, schi…
65y · Male·Strychnine toxicity
Christopher Griffin, aged 65, died from strychnine poisoning at his home in South Australia. He had experienced progressive cognitive decline over five years (suspected Lewy Body or semantic dementia, though neuropatholo…
53y · Female·Aspiration pneumonia in a woman with Alzheimer's disease complicating Trisomy 21
Melissa Wright, age 53, had Down syndrome and Alzheimer's disease. She lived in supported disability accommodation funded by the NDIS. From 2023, she experienced rapid cognitive and physical decline, losing the ability t…