558
Total cases
43%
Preventable or possibly preventable
49%
With coroner recommendations
24%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
79y · Female·Non-convulsive status epilepticus on a background of urinary tract sepsis and pn…
Carol Fay Glascott, 79, with Down syndrome, intellectual disability, epilepsy, and Lewy body dementia, died from non-convulsive status epilepticus on a background of urinary tract sepsis and pneumonia. In September 2024,…
41y · Female·Aspiration pneumonia complicating an ischaemic stroke in a woman with epilepsy, …
Laura Claire Brady, aged 41, was a Specialist Disability Accommodation (SDA) resident with cerebral palsy, severe epilepsy, and intellectual disability. In December 2024, she deteriorated while in SDA care, presenting wi…
61y · Female·Complications of advanced relapsing-remitting multiple sclerosis (palliated)
Amanda Joy Taylor, age 61, died on 1 October 2025 at her disability support accommodation facility in Melbourne from complications of advanced relapsing-remitting multiple sclerosis. She had lived in the facility since M…
74y · Male·Left cerebral ischaemic stroke caused by cerebral arterial cardioembolism
Desmond George Buckby, a 74-year-old prisoner detained under the Dangerous Prisoners (Sexual Offenders) Act, suffered a massive left cerebral ischaemic stroke caused by cardioembolism while in Wolston Correctional Centre…
67y · Male·Complications of chronic obstructive pulmonary disease
A 67-year-old man with end-stage chronic obstructive pulmonary disease was serving a lengthy prison sentence in Corrective Services NSW custody at Long Bay Hospital's Aged Care and Rehabilitation Unit. In early October 2…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…