438
Total cases
66%
Preventable or possibly preventable
73%
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.
78y · Male·Complications of acute renal impairment in the setting of pelvic and lumbar frac…
Garry Ledger, 78-year-old South Australian visitor, died three weeks after falling on a Melbourne tram on 28 August 2025. While boarding tram route 16, he fell during tram acceleration while using his Myki card and befor…
84y · Male·bronchopneumonia complicating C2 odontoid fracture (palliated) due to fall on a …
Wayne Malcolm Clark, aged 84, with advanced Alzheimer's and vascular dementia, fell in a secure residential aged care facility and sustained a C2 odontoid fracture. He died on 23 August 2023 from bronchopneumonia complic…
77y · Female·Ischaemic heart disease
Gayle Patricia Carley, 77, collapsed unwitnessed at home with acute ischaemic heart disease on 19 October 2023. Ambulance paramedics arrived and initiated emergency treatment, but a MICA paramedic inadvertently administe…
91y · Female·Aspiration pneumonia in a woman with multiple co-morbidities
91-year-old woman with disability living in specialist disability accommodation who died from aspiration pneumonia. She had documented moderate oropharyngeal dysphagia from prior stroke, managed with pureed diet and thic…
48y · Male·Pulmonary thromboembolism
Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…
47y · Male·Multiple blunt force injuries to the neck, chest and lower limbs sustained in a …
A 47-year-old male passenger died from multiple blunt force injuries (bilateral pneumothoraces, pulmonary contusions, ruptured spleen, pelvic fractures, cervical spine fracture with spinal cord haemorrhage) from a high-s…