233
Total cases
60%
Preventable or possibly preventable
64%
With coroner recommendations
30%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
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…
44y · Female·Pulmonary thromboembolism complicating a fractured left ankle (not operated), su…
A 44-year-old woman died from pulmonary thromboembolism 27 days after sustaining a Weber B ankle fracture from a fall. She was managed conservatively with a CAM boot then below-knee cast, with progressive immobilisation …
53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
70y · Male·Metastatic melanoma with ischaemic heart disease as a contributing condition
Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…
11y · Male·Bronchopneumonia and small bowel necrosis with perforation, in a boy with multic…
Child MML was an Aboriginal boy born in April 2010 who suffered catastrophic abusive head trauma at eight months old in December 2010, causing severe lifelong neurological impairment including cerebral palsy, uncontrolle…
53y · Female·Unascertained (presumed drowned)
Kathleen Smith, a 53-year-old podiatrist, disappeared on 15 July 2024 and is presumed to have drowned at Sorrento Back Beach. She was experiencing severe anxiety about upcoming foot surgery due to severe flatfoot deformi…