22
Total cases
64%
Preventable or possibly preventable
77%
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.
86y · Female·Metastatic ovarian cancer (high-grade serous carcinoma)
An 86-year-old woman serving a life sentence died of metastatic ovarian cancer in palliative care. After diagnosis in April 2023, treatment was appropriately limited to symptom management given her advanced dementia, mak…
75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…
A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…
71y · Female·complications of metastatic endometrial carcinoma, treated palliatively
Corazon Contreras Keeley, a 71-year-old woman with postmenopausal bleeding, was investigated for possible endometrial cancer. Dr K. performed a hysteroscopy with dilation and curettage (HDC) on 29 November 2019, observin…
Female·Not definitively stated in judgment; death followed complications from initial s…
This judgment concerns a pre-inquest motion by the Christian Congregation of Jehovah's Witnesses challenging the scope of a coronial inquiry into Heather Winchester's death. Mrs Winchester died following emergency surger…
27y · Female·multiple injuries sustained from fall from 30-storey building
Ms L, a 27-year-old German national, died by suicide on 4 March 2021 after jumping from a 30-storey building in Perth. She had experienced depression since 2016, exacerbated by recent diagnoses of chlamydia and HPV16 in …
62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…
A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy fo…