527
Total cases
31%
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.
66y · Male·haemoptysis from a cavitated lesion of the left lung with aspergillus and candid…
A 66-year-old man serving a life sentence at Yatala Labour Prison died from haemoptysis caused by a cavitated lung lesion with aspergillus and candida infection. He had multiple chronic comorbidities including ischemic h…
52y · Female·Large bowel obstruction secondary to sigmoid volvulus
Lisa Gladman, a 52-year-old woman with congenital encephalopathy and intellectual disability living in supported disability accommodation funded under the NDIS, died from a large bowel obstruction secondary to sigmoid vo…
63y · Male·Aspiration pneumonitis in a man with Down syndrome
John Patrick Button, a 63-year-old Aboriginal man with Down syndrome, died from aspiration pneumonitis at Austin Hospital on 17 February 2025, five days after admission. He presented with seizure and severe respiratory d…
29y · Male·Arrhythmia of unascertained cause
Jake Andrew Carter, a 29-year-old unsentenced prisoner, died from a cardiac arrhythmia of unascertained cause while in custody at John Morony Correctional Centre on 13 January 2025. He presented with acute breathlessness…
67y · Female·Aspiration pneumonia in a woman with advanced multiple sclerosis
Julie Jane Lambert, a 67-year-old woman with advanced multiple sclerosis, died from aspiration pneumonia at Sandringham Hospital on 8 December 2024. She had been residing in a specialist disability accommodation (SDA) as…
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…