397
Total cases
42%
Preventable or possibly preventable
49%
With coroner recommendations
33%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
66y · Male·haemoptysis from a cavitated lesion of the left lung with aspergillus and candid…
A 66-year-old man serving a life sentence at Yatala Labour Prison died from haemoptysis caused by a cavitated lung lesion with aspergillus and candida infection. He had multiple chronic comorbidities including ischemic h…
67y · Female·Multisystem failure complicating urosepsis and acute myeloid leukaemia
A 67-year-old woman with intellectual disability living in specialist disability accommodation was diagnosed with Acute Myeloid Leukaemia in May 2024 and received low-intensity chemotherapy at home. In July 2024, she was…
53y · Female·Pneumonia and septic arthritis on a background of atypical parkinsonian syndrome
A 53-year-old woman with intellectual disability, schizoaffective disorder and progressive neurological decline presented to hospital with fevers and was extensively investigated over four months for septic arthritis and…
52y · Female·Large bowel obstruction secondary to sigmoid volvulus
Lisa Gladman, a 52-year-old woman with congenital encephalopathy and intellectual disability living in supported disability accommodation funded under the NDIS, died from a large bowel obstruction secondary to sigmoid vo…
50y · Male·Unascertained
Ivan Spudic, 50, was a long-term heroin user receiving methadone maintenance at the New Beginnings clinic. He had HIV (well-controlled), liver cirrhosis, and multiple mental health conditions. Found deceased at home in T…
2y · Female·Sepsis, caused by an aggressive bacterial infection on a background of Group A S…
Pippa Mae White, aged 2 years 10 months, died from sepsis caused by Group A Streptococcus infection. The coroner found her death wholly preventable. Critical clinical lessons: failure to activate the Paediatric Sepsis Pa…