388
Total cases
18%
Preventable or possibly preventable
32%
With coroner recommendations
13%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
47y · Male·Metastatic adenocarcinoma of the gastroesophageal junction
Ashley John Bryant was a 47-year-old man subject to a post-sentence supervision order for serious sex offences, residing in a state-managed residential facility. In April 2024, he was diagnosed with metastatic adenocarci…
52y · Male·perforation of a hollow viscus complicating oesophageal cancer in a man with cer…
Adam Barry, a 52-year-old man with cerebral palsy, dysphagia, and epilepsy, was diagnosed with metastatic oesophageal cancer in February 2024 after presenting to hospital with vomiting. Living in Specialist Disability Ac…
70y · Male·metastatic gastric adenocarcinoma
A 70-year-old man with prior bladder cancer was undergoing routine CT surveillance. Stomach cancer signs were clearly visible on February 2017 and February 2018 CT scans but failed to be detected by consulting radiologis…
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…
Male·stage 4 lung cancer with pleural metastases
Kenneth Plumstead died of stage 4 lung cancer with pleural metastases at Launceston General Hospital on 18 October 2014, receiving appropriate palliative care including morphine pain relief. Eleven years later, his widow…
57y · Male·Metastatic lung adenocarcinoma
Wen Liang Zhang was a 57-year-old remand prisoner diagnosed with metastatic lung adenocarcinoma shortly after arrest on 26 September 2025. He declined chemotherapy and radiotherapy, choosing palliative pain management in…