143
Total cases
33%
Preventable or possibly preventable
47%
With coroner recommendations
22%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
72y · Male·Complications of suspected upper gastrointestinal tract haemorrhage, hospital ac…
A 72-year-old man with metastatic squamous cell lung cancer and multiple serious comorbidities was admitted to Ballarat Hospital in July 2024 with lethargy, fatigue, and rapid atrial fibrillation. Due to medication chart…
70y · Male·Chronic kidney disease, with atherosclerotic cardiovascular disease and type 2 d…
Francis Lex Deemal, a 70-year-old Indigenous man from Hope Vale, Cape York, died at Mareeba Hospital on 2 August 2023 from chronic kidney disease, with atherosclerotic cardiovascular disease and type 2 diabetes as contri…
71y · Male·metastatic papillary renal cell carcinoma
Robert Bell-Williams, aged 71, died from metastatic papillary renal cell carcinoma while in lawful custody at Long Bay Hospital on 1 February 2024. Imprisoned since 2012, he was diagnosed with renal cell carcinoma in 202…
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
82y · Male·Complications of large bowel obstruction in a man with diverticular disease and …
An 82-year-old man died from complications of large bowel obstruction secondary to a sigmoid mass while incarcerated at Port Phillip Prison. He presented with abdominal pain and vomiting following a fall, and imaging con…
82y · Male·Ischaemic and hypertensive heart disease
An 82-year-old man with extensive medical comorbidities including ischaemic heart disease, triple vessel coronary artery disease (previously bypass grafted), diabetes, chronic kidney disease, and dementia died suddenly i…