419
Total cases
67%
Preventable or possibly preventable
74%
With coroner recommendations
41%
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…
68y · Male·Cardiac arrest - unascertained etiology with multiple contributing factors inclu…
Wayne Thomas Kerle, 68, was arrested at his home for cannabis possession. Queensland Ambulance Service paramedics assessed him when he reported respiratory distress but cleared him for police custody after a limited exam…
78y · Female·Hypernatraemia in the setting of lowered oral intake
Kerrie Berlowitz, 78, with cerebral palsy and intellectual disability, died of hypernatraemia (severe sodium elevation) due to dehydration. Living in supported disability accommodation in Carrum, she progressively refuse…
24y · Female·Mixed drug toxicity
Sheridan Burnell, 24, died from mixed drug toxicity following an intentional overdose of prescription medications (lamotrigine and quetiapine) on 2 January 2021. Her mental health care was reasonable and appropriate. The…
38y · Female·Pulmonary thromboembolism secondary to deep venous thrombosis due to promethazin…
Elizabeth Jean Hanlon, aged 38, died from pulmonary thromboembolism secondary to deep venous thrombosis following a promethazine overdose. She had complex mental health diagnoses including borderline personality disorder…
82y · Male·Multiple injuries sustained in a motor vehicle incident (car vs. tree, driver)
An 82-year-old man with recently diagnosed emerging Alzheimer's disease presented to his GP with lower respiratory infection and mild confusion. The GP appropriately arranged hospital admission via family transport. Howe…