534
Total cases
32%
Preventable or possibly preventable
37%
With coroner recommendations
19%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
74y · Male·Pulmonary thromboembolism due to right deep vein thrombosis
Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond t…
37y · Female·morbid obesity with dilated cardiomyopathy and obstructive sleep apnoea
Ms UT, a 37-year-old woman with treatment-resistant schizophrenia, died of morbid obesity with dilated cardiomyopathy and obstructive sleep apnoea. She was prescribed clozapine, an effective but potentially cardiotoxic a…
67y · Female·Pulmonary thrombo-embolism secondary to deep venous thrombosis, with contributin…
Vicki Grigg, 67, died from pulmonary embolism three days after discharge from Goulburn Valley Health. She had been admitted with influenza A exacerbating asthma and COPD, and received standard-dose anticoagulation prophy…
67y · Male·Multi-organ failure secondary to acute myocardial infarction secondary to in-ste…
Christopher Doughty, 67, was admitted to Hervey Bay Hospital on 17 September 2021 with a life-threatening gastrointestinal bleed two months after receiving coronary stents. The bleed was likely caused by dual antiplatele…
74y · Male·Probable respiratory failure in a man with advanced motor neurone disease in the…
Philip McHardy, a 74-year-old man with advanced motor neurone disease (MND), died of respiratory failure on 13 July 2025 after a five-month hospital admission. He was dependent on non-invasive ventilation (NIV) for up to…
67y · Male·Complications of chronic obstructive pulmonary disease
A 67-year-old man with end-stage chronic obstructive pulmonary disease was serving a lengthy prison sentence in Corrective Services NSW custody at Long Bay Hospital's Aged Care and Rehabilitation Unit. In early October 2…