109
Total cases
78%
Preventable or possibly preventable
76%
With coroner recommendations
31%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
41y · Female·Injuries sustained in a fall from a height
VNP was a 41-year-old woman with longstanding bipolar disorder type 1, chronic pain from endometriosis, and substance misuse history who died by suicide on 10 July 2023. She had experienced homelessness, family estrangem…
51y · Female·Unintentional prescription drug poisoning due to central nervous system depressi…
A 51-year-old woman with chronic pain, depression, and longstanding medication misuse died from unintentional prescription drug poisoning. She had been prescribed high-risk combinations of opioids and benzodiazepines ove…
34y · Female·Combined drug toxicity (gabapentin, oxycodone, tramadol, diazepam, citalopram, d…
A 34-year-old woman with complex medical history including chronic pain, sleep disorder, anxiety and PTSD died from combined drug toxicity involving gabapentin, oxycodone, tramadol, diazepam, citalopram, desmethylvenlafa…
57y · Female·aspiration of gastric contents caused by combined drug and alcohol toxicity resu…
A 57-year-old woman with complex medical and mental health conditions died from aspiration of gastric contents caused by combined drug and alcohol toxicity. She had severe chronic pain following abdominal surgeries, opio…
42y · Female·Pneumonia, underlying severe cerebral palsy
Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…
60y · Male·Unknown; likely suicide but natural causes or accident cannot be excluded
Wayne Michael Parker, a 60-year-old man with chronic degenerative spinal disease and chronic pain managed with opioid medications, disappeared on 3 June 2023 from Mount Barker, Western Australia. He drove to Mount Magog …