58
Total cases
71%
Preventable or possibly preventable
76%
With coroner recommendations
40%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
83y · Male·Metastatic melanoma
Maxwell John Beever, aged 83, died from metastatic melanoma on 8 July 2022 while in custody at Robina Hospital. A suspicious skin lesion was documented on 26 February 2021 but not investigated until 26 June 2021, delayin…
93y · Male·Complications of invasive squamous cell carcinoma of the scalp
Donald Morley, aged 93, died at Claire Holland House hospice on 12 July 2024 while serving a nine-year sentence for murder. He was under 24/7 custodial supervision. The cause of death was complications of invasive squamo…
54y · Female·Severe burns sustained in a house fire (palliated)
Carol Fay Slade, a 54-year-old woman with acquired brain injury from a 2003 motorcycle accident and mobility limitations, died from severe burns sustained in a house fire at her public housing property in Shepparton. The…
73y · Male·Gregory Frank Burkhalter: carbon monoxide toxicity due to inhalation of carbon m…
Two elderly US-born residents died in a house fire caused by a 120-volt electric blanket operating on Australia's 230-volt grid, resulting in insulation failure and combustion. Mr Burkhalter (73) died from carbon monoxid…
45y · Female·Complications of sepsis secondary to sacral pressure wound in a woman with genet…
Kristy Ann Mitchener, a 45-year-old woman with severe intellectual disability, genetic developmental and epileptic encephalopathy, and oesophageal dysmotility, died from sepsis secondary to a sacral pressure ulcer despit…
78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…
78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…