673
Total cases
45%
Preventable or possibly preventable
47%
With coroner recommendations
29%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
78y · Female·Multiple organ failure secondary to sepsis and renal failure due to bronchopneum…
A 78-year-old woman with cognitive impairment, depression, and complex care needs fell at home on 11 February 2022. Her sons delayed seeking medical help for 4 days, during which she developed aspiration pneumonia and wa…
78y · Male·Complications of acute renal impairment in the setting of pelvic and lumbar frac…
Garry Ledger, 78-year-old South Australian visitor, died three weeks after falling on a Melbourne tram on 28 August 2025. While boarding tram route 16, he fell during tram acceleration while using his Myki card and befor…
84y · Male·bronchopneumonia complicating C2 odontoid fracture (palliated) due to fall on a …
Wayne Malcolm Clark, aged 84, with advanced Alzheimer's and vascular dementia, fell in a secure residential aged care facility and sustained a C2 odontoid fracture. He died on 23 August 2023 from bronchopneumonia complic…
75y · Male·combined effects of subdural haematoma and facial fractures following a fall com…
A 75-year-old man with advanced Alzheimer's dementia residing in aged care died in hospital following a fall at his residential facility. He was assessed as high falls risk at the aged care facility. After collapsing and…
92y · Male·respiratory failure secondary to bilateral pleural effusions on a background of …
Hans Biermann, aged 92, died on 1 March 2023 following respiratory failure secondary to bilateral pleural effusions and rib fractures sustained in a fall at Regis Playford aged care facility on 23 February 2023. Mr Bierm…
91y · Female·Aspiration pneumonia in a woman with multiple co-morbidities
91-year-old woman with disability living in specialist disability accommodation who died from aspiration pneumonia. She had documented moderate oropharyngeal dysphagia from prior stroke, managed with pureed diet and thic…