14
Total cases
50%
Preventable or possibly preventable
86%
With coroner recommendations
21%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
17y · Male·Gunshot wound to the head
Dustin Buckley, 17, died from a gunshot wound to the head at Royal Melbourne Hospital on 27 August 2017. The incident occurred during target shooting at Cat Track when KD fired a .22 rifle that discharged, striking Dusti…
41y · Male·heart failure related to exsanguination due to traumatic rupture of an arteriove…
Nicholas Summers, a 41-year-old kidney transplant recipient, died from traumatic rupture of an arteriovenous fistula with massive hemorrhage on 16 February 2016. He had returned to Tasmania under nephrologist Dr M.'s car…
61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a c…
Kelvin Moulds, a 61-year-old man, died of hypoxic encephalopathy following a cardiac arrest caused by self-removal of a central venous catheter (CVC) on day 14 post-bilateral lung transplant. The CVC was still in situ de…
Male·non-specific interstitial pneumonia
Simon John Sharpe, a sentenced prisoner with incurable non-specific interstitial pneumonia, died on 30 June 2017 at Fiona Stanley Hospital from progression of his lung disease. Throughout his 17-month imprisonment, Sharp…
59y · Female·Multiorgan failure and polymicrobial sepsis secondary to severe bone marrow fail…
A 59-year-old woman with renal transplant died from multiorgan failure and sepsis secondary to severe bone marrow failure caused by azathioprine toxicity. She had an undiagnosed genetic polymorphism (TPMT *3A/*3A homozyg…
35y · Male·intraperitoneal haemorrhage from an anastomotic leak from a transplanted renal a…
Luke Wood, a 35-year-old kidney transplant recipient, died 11 days post-transplant from intraperitoneal haemorrhage due to anastomotic leak from the transplanted renal artery. While post-operative inpatient care and init…