394
Total cases
18%
Preventable or possibly preventable
31%
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.
Male·combined effects of cardiomyopathy and metastatic melanoma
Geoffrey Croft, imprisoned in New South Wales, developed melanoma diagnosed late during custodial care. He first noticed a lesion on his back in October 2019 but wasn't examined medically until March 2020 (when bleeding …
66y · Male·haemoptysis from a cavitated lesion of the left lung with aspergillus and candid…
A 66-year-old man serving a life sentence at Yatala Labour Prison died from haemoptysis caused by a cavitated lung lesion with aspergillus and candida infection. He had multiple chronic comorbidities including ischemic h…
67y · Female·Multisystem failure complicating urosepsis and acute myeloid leukaemia
A 67-year-old woman with intellectual disability living in specialist disability accommodation was diagnosed with Acute Myeloid Leukaemia in May 2024 and received low-intensity chemotherapy at home. In July 2024, she was…
61y · Male·multiple injuries
Bryan Jeffrey Dodd, a 61-year-old man with metastatic colorectal cancer, was admitted to Royal Perth Hospital in September 2023 for acute pain management. Severe, unmanageable pain led him to escalate use of oxycodone an…
84y · Male·Metastatic pancreatic adenocarcinoma with end-stage renal failure and atrial fib…
Thumbarian Govender, aged 84, was serving a 20-year sentence for drug importation when diagnosed with metastatic pancreatic cancer in January 2026 with an estimated 6-month prognosis. He completed an Advance Care Directi…
80y · Male·Metastatic retroperitoneal liposarcoma
John Carlos Gonzalez, aged 80, was incarcerated at Ravenhall Correctional Centre serving a 24-year sentence for murder. He had a history of recurrent retroperitoneal liposarcoma diagnosed in 2018, treated with complex ab…