2,612
Total cases
62%
Preventable or possibly preventable
67%
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…
33y · Female·Hanging
A 33-year-old woman with major depressive disorder died by hanging while voluntarily admitted to a mental health inpatient unit. She was stabilizing on medication and scheduled for transfer to a private facility. The cor…
61y · Female·Unascertained (natural causes)
Ms Harris, aged 61, with intellectual disability, autism spectrum disorder, and multiple medical conditions (including aortic regurgitation, hypothyroidism, dyspnoea, hyperlipidaemia, and obesity), was living in supporte…
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…
25y · Female·Mixed drug consumption (pregabalin, oxycodone, desmethylvenlafaxine, aripiprazol…
Kaylah Veronica Sarah Woollard, age 25, died from mixed drug toxicity in the context of significant natural disease. She had WHO Class III obesity (BMI 94.5), cardiac hypertrophy, and mental health conditions (depression…
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…