30
Total cases
63%
Preventable or possibly preventable
87%
With coroner recommendations
37%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
78y · Female·Complications of mandibular fractures sustained in a fall, in the setting of mal…
Frances Hayden, 78, died from complications of mandibular fractures sustained in a fall at an aged care facility. She had long-standing schizoaffective disorder with associated anorexia, resulting in severe malnutrition …
84y · Male·Ischaemic heart disease and coronary artery atherosclerosis in the setting of ty…
Jonathan Uphill, an 84-year-old man with extensive comorbidities including type 2 diabetes, hypertension, and prior cardiac risk factors, died of ischaemic heart disease with coronary artery atherosclerosis. He underwent…
51y · Female·Methemoglobinemia in the context of lignocaine use
Danielle Cadan, 51, died from methemoglobinemia following a tooth extraction under lignocaine anaesthetic at a regional health service. The lignocaine was administered in normal therapeutic dose but triggered this rare l…
54y · Male·Hypoxic/ischaemic brain damage caused by blood loss and airway obstruction due t…
A 54-year-old male was assaulted in a nightclub with a single punch causing orbital and facial fractures and posterior epistaxis. He presented to the Royal Hobart Hospital ED with active bleeding. Critical deficits in hi…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…
59y · Female·complications of abscesses following dental extraction, in a woman with cerebral…
Angela Cuthbert, a 59-year-old woman with severe cerebral palsy and dysphagia, died from complications of abscesses following extraction of all 14 teeth under general anaesthetic. Surgery occurred 20 June 2022; she devel…