389
Total cases
43%
Preventable or possibly preventable
49%
With coroner recommendations
34%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
57y · Female·Urosepsis due to an obstructing renal calculus in a woman with multiple comorbid…
Christine Giliberto, aged 57, died of urosepsis from an obstructing kidney stone. She lived in supported disability accommodation with severe lifelong disabilities (hydrocephalus, cerebral palsy, non-verbal). An obstruct…
64y · Male·Complications of Severe Cerebral Palsy (Palliated)
Guy Edwin Gellibrand, 64, lived in supported NDIS accommodation with severe cerebral palsy, quadriplegia and non-verbal communication. In late September 2025, he presented to Monash Medical Centre with acute illness pres…
66y · Male·Complications arising from the combined features of HIV infection, multiple cere…
Grant Douglas Griffiths, a 66-year-old man with HIV, multiple cerebrovascular accidents, progressive dementia, and other comorbidities, deteriorated significantly after admission to hospital in March 2022 due to function…
74y · Female·Aspiration pneumonia
Annette Kelly, 74 years old, died from aspiration pneumonia at Wantirna Palliative Care after brief hospitalisation at Box Hill Hospital in October 2025. She was a long-term Specialist Disability Accommodation resident w…
38y · Female·Pulmonary thromboembolism secondary to deep venous thrombosis due to promethazin…
Elizabeth Jean Hanlon, aged 38, died from pulmonary thromboembolism secondary to deep venous thrombosis following a promethazine overdose. She had complex mental health diagnoses including borderline personality disorder…
64y · Female·Urosepsis and pneumonia on a background of dementia and cognitive decline
Loretta Therese Ward, aged 64, was living in Specialist Disability Accommodation (SDA) under NDIS support due to Lewy Body dementia and cognitive decline when she developed progressive illness in late 2024. On 24 Februar…