2,661
Total cases
61%
Preventable or possibly preventable
66%
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.
34y · Male·Hanging (suicide by ligature)
Justin Cordy, a 34-year-old man, died by suicide via hanging in the Alexander Maconochie Centre (AMC) prison on 26 February 2023 while on remand. The coroner found multiple critical system failures contributed to his dea…
45y · Male·Suicide by hanging
45-year-old Aboriginal man with schizophrenia presented to ED after wrist-cutting attempt. Police apprehended him and admitted as involuntary mental health patient under Form 9 requiring psychiatric assessment, but absco…
30y · Male·Hanging
This case involved a 30-year-old Iranian asylum seeker with acute psychosis who presented to emergency with weapons and paranoid ideation. He was admitted to an inpatient psychiatric unit, diagnosed with first-episode ps…
40y · Male·multiple injuries
Eden Ryan Zanetti, age 40, died by suicide on 21 November 2024, jumping from a cliff at Boya Quarry, falling approximately 40 metres. He had a 10+ year history of schizoaffective disorder with treatment-resistant psychos…
42y · Female·Multiple drug toxicity, with aspiration of vomit also contributing
Ms UL, a 42-year-old woman, died on 16 July 2022 from multiple drug toxicity at her residence in Ainslie, ACT. Post-mortem toxicological analysis revealed lethal concentrations of methadone, morphine, and codeine, along …
67y · Male·glioblastoma of the central brain
Russell Longmore, a 67-year-old Aboriginal man with schizophrenia on involuntary mental health treatment, was hospitalized in February 2025 after a fall that revealed a malignant brain tumour (glioblastoma). When neurosu…