329
Total cases
55%
Preventable or possibly preventable
67%
With coroner recommendations
15%
Escalation failure identified
Specialty tagging, error classification, and clinical flags are AI-generated and may contain inaccuracies. Always refer to the original finding.
78y · Male·Complications of acute renal impairment in the setting of pelvic and lumbar frac…
Garry Ledger, 78-year-old South Australian visitor, died three weeks after falling on a Melbourne tram on 28 August 2025. While boarding tram route 16, he fell during tram acceleration while using his Myki card and befor…
75y · Male·combined effects of subdural haematoma and facial fractures following a fall com…
A 75-year-old man with advanced Alzheimer's dementia residing in aged care died in hospital following a fall at his residential facility. He was assessed as high falls risk at the aged care facility. After collapsing and…
34y · Male·95% total body surface area burns and inhalational injury sustained in a vehicle…
TE, a 34-year-old male, died on 22 February 2024 from 95% total body surface area burns and inhalational injury sustained in a deliberate vehicle fire on the Monash Freeway. The coroner confirmed this was suicide, noting…
76y · Male·Traumatic head, ribs, pelvic and spinal injuries sustained in a motor vehicle in…
A 76-year-old man with schizophrenia, depression, Klinefelter syndrome, and poorly controlled diabetes was struck by a car as a pedestrian on 19 December 2024 while crossing Middleborough Road in Box Hill South outside a…
14y · Male·Retroperitoneal haemorrhage secondary to abdominal injuries sustained in a motor…
A 14-year-old boy riding an illegally high-powered e-scooter (capable of 40-50 km/h) collided with a utility vehicle at a residential intersection. The e-scooter exceeded legal speed limits and age restrictions under Vic…
51y · Male·Traumatic brain injuries resulting from blunt head trauma: multiple calvarial an…
Adrian Garcia, 51, died from traumatic brain injuries sustained during an assault in a public park in Sorell, Tasmania on 10 March 2021. He was heavily intoxicated when struck by a baseball bat multiple times by his fian…