141
Total cases
33%
Preventable or possibly preventable
48%
With coroner recommendations
21%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
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…
38y · Male·Diabetic ketoacidosis secondary to pyelonephritis in a man with insulin dependen…
A 38-year-old man with insulin-dependent diabetes, partial blindness, gastroparesis, seizures, chronic kidney disease and peripheral vascular disease died from diabetic ketoacidosis precipitated by pyelonephritis. He had…
51y · Female·Multiorgan failure in the setting of WHO Class III obesity, chronic excessive al…
A 51-year-old woman with WHO Class III obesity, chronic alcohol consumption, and anaemia died of multiorgan failure following admission with community-acquired pneumonia and respiratory failure. She presented with abdomi…