It can also be seen on . The 18-year-old TAFE student's death was featured in a Four Corners report, which revealed he presented to Broken Hill Hospital's emergency department four times before vital signs observations were administered. "I've worked in 13 different locum hospitals since I've retired and I've never seen anything like Broken Hill in my entire career," he said. He would follow them to Sydney on a commercial flight. Alex Braes, 18, died at Sydney's Royal Prince Alfred Hospital about 46 hours after limping into Broken Hill Base Hospital at 3am on September 20, 2017. It's something that troubles local MP Roy Butler. Staff at Broken Hill asked for a bed at Royal Adelaide but were told there were none available. While Broken Hill Hospital's deficiencies did not cause or contribute to Braes' death, the hospital's administration and the Far West Local Health District downgraded the severity classification of the incident. Dr Hooper, who resigned from his position as a senior visiting medical officer at Broken Hill Hospital two months ago, told the inquest yesterday that Mr Braes' death was a "profound event" in his life. The following month he began to experience pain in his knee. "I feel heartbroken that I still have my children and that you've lost your boy.". "And I think that the clinicians who would have been with him when he was so sick in emergency will not forget him.". Dr Greenberg said the teenager was in a "relatively good" conditionfor someone who was critically ill. By the time Alex was diagnosed with a bacterial infection he was in septic shock and needed to be medically evacuated to Adelaide. New South Wales Health Department figures show Broken Hill has the highest potentially avoidable death rate in New South Wales at 189 deaths per 100,000 people and most recent figures show it is rising. Alex Braes, 18, was only tested for . A man died just hours after entering a secure mental health unit. It was only then that the source of Alex's pain was finally discovered he had an infected toenail which no-one had picked up on his three previous presentations. "This was a seriousand unacceptabledeficiency in his care and it was a missed opportunity to identify his underlying, evolving illness," she said. He was taken to Royal Prince Alfred Hospital in Sydney but went into cardiac arrest and died soon after arriving during the early hours of September 22, 2017. As for the delays in Braes' transfer, the coroner pointed out that the teen was not taken to South Australia's (SA) Royal Adelaide Hospital despite the facility being the closest hospital suitable for his care. A coroner has blasted a NSW hospital for attempting to avoid an investigation into a teenager's death from sepsis after he was sent home from its emergency department, finding efforts to deny the significance of the tragedy inexcusable and deeply distressing to his family. The inquiry was launched after an investigation by The Sydney Morning Herald exposed troubling circumstances of three deaths and a series of near-misses at hospitals across western NSW. the death prevention role of the coroner family privacy sensitivity of the findings possible harm from making an investigation publically available In general, authorised findings for publication will include: all public inquest findings motor vehicle crashes long-term missing persons cases homicides after the criminal process has been completed It was far too late. This was due to a business rule, which discouraged staff from taking vitals during the triage stage in order to improve efficiency. 'We failed him' Alex Braes, of Broken Hill, died in the early hours of Sept. 22, 2017, upon arriving at Royal Prince Alfred Hospital in Sydney, 7News.com.au reported. It would eventually take a whole year for an investigation to be done and that only happened because the doctors repeatedly lobbied the Ministry of Health and, ultimately, wrote to NSW Health Minister Brad Hazzard, to intervene. Tragically, what worked against Mr Braeswas his overall health and age, the inquest heard. A traumatised doctor has broken down in tears at an inquest, reflecting on how a relatively well teenager was joking with his father the night before his sudden death. Mr Braes told the inquest that even once Alex became gravely ill, there was no ambulance available to take him to Broken Hill Hospital, no hospitals willing to admit him in Adelaide and no pilot available to fly him to Sydney. A NSW coronial inquest is examining the care Mr Braes received at Broken Hill Hospital, why his vital signs weren't taken until his third visit to the emergency department in two days and why it took hours for the 18-year-old to be medically evacuated out of the country town. In conjunction with the Chief Coroner, the Judicial College delivers a varied training programme for all coroners involving induction, continuation and one-day training on specific topics. Key points: Mr Braes' cause of death identified as multi-organ failure due to sepsis from a group A streptococcus infection Part 1 Requesting the Autopsy Report 1 Understand the purpose of an autopsy. She recommended NSW and SA health departments urgently agree to cross-border transfers of critically ill patients from Broken Hill. Alex Braes, of Broken Hill, died in the early hours of Sept. 22, 2017, upon arriving at Royal Prince Alfred Hospital in Sydney, 7News.com.au reported. The death of a healthy 18-year-old man who first attended a hospital with moderate knee pain is almost incomprehensible, she said. 7 Callum Jones: Sprained Ankle Causes Fatal Blood Clot. Broken Hill Hospital management downgraded the categorisation of Alex's death, meaning it wasn't referred immediately for an investigation, as is required under the state's Health Administration Act. Each season is dedicated to a different series in horror. The first doctor to treat a limping teenager, whose sudden death from a fast-acting infection is under coronial investigation, says in retrospect he should have taken a full set of basic readings such as blood pressure. Alex died in the early hours of September 22, 2017, at Royal Prince Alfred Hospital, Sydney, after being transferred from his local hospital. Alex Murdaugh called 911 on the evening of June 7, 2021, and said he'd found his son and wife dead when he returned home from a one-hour visit with his mother, who has dementia. Alex went into cardiac arrest and died upon arrival at Royal Prince Alfred Hospital in Sydney. "[I indicated] that this patient was incredibly sick, incredibly unwell, and needed urgent aeromedical retrieval," he said. Two days before his death, Braes presented to Broken Hill Hospital with severe leg pain, but the facility's staff did not check his full vital signs, Ryan said. The Deputy State Coroner has criticised a regional hospitals treatment of a boy who was repeatedly sent home before dying from sepsis. Alex Braes presented to Broken Hill Hospital four times over a more than 30 hour period in September 2017 (Noah Schultz-Byard) The second day of hearings heard from Dr David Hooper, who reviewed Alex during his third presentation to the local hospital on September 20, 2017. This resulted in Braes' parents being denied a formal investigation "for an inexcusable length of time," Ryan said. Health workers union takes fight for kitchen staff in NSW aged care home to federal court, Original reporting and incisive analysis, direct from the Guardian every morning. Broken Hill hadn't been able to get a GP that week to staff the fast-track clinic which saw less-serious patients, so that put enormous pressure on the emergency department. a coroner has heard. But so shocking is his case that it's prompted a group of clinicians who worked at Broken Hill Hospital to blow the whistle on what they believe is a hospital that had dangerous, systemic failures for years. Broken Hill teenager Alex Braess parents remember him as a ray of sunshine, a funny and smart young man ready to live a full life. After his ultrasound, he expected a doctor to review his results but the emergency department was so busy, no-one could see him. Mr Braes died a little more than an hour after being admitted. Australian Institute of Health and Welfare figures released in July show the further Australians live from capital cities, the higher the rate of potentially avoidable deaths. AEST = Australian Eastern Standard Time which is 10 hours ahead of GMT (Greenwich Mean Time), abc.net.au/news/alex-braes-inquest-findings-health-systems-criticised/101109422, Get breaking news alerts directly to your phone with our app, Help keep family & friends informed by sharing this article, China leaving US behind on development of critical technologies, report finds, Former minister takes 'absolute responsibility' for Robodebt, admits defending scheme despite knowing it could be unlawful, 'Sickening, callous and brazen': Sydney man dies in hail of bullets in front of 12yo son, Evelyn worked three jobs when she was in her 20s to build up her super. My first thought was I havent finished obs for him, I havent done anything for him, have I missed something? she told the inquest. She said evidence highlightedthat Mr Braes was effectively refused admission to a South Australian tertiary hospital on September 21, 2017. Infectious diseases specialist Phillip Braslins said he was considering amputation after 18-year-old Alex Braes went into septic shock in Broken Hill Base Hospital on September 21 . "Certainly other hospitals will highlight a second presentation or third presentation, [to ask] 'have we missed something?'" We acknowledge Aboriginal and Torres Strait Islander peoples as the First Australians and Traditional Custodians of the lands where we live, learn, and work. Please confirm you want to block this member. Ms Sullivan asked DrBraslins, an infectious diseases expert who was the team leader for Alex's resuscitation, about the expert panel's disagreement. Alex Braes, 18, died on 22 September 2017 from multi-organ failure due to sepsis from a Group A streptococcus infection. Now she believes she's being penalised, Australia loses first wicket on day two but still on top in Indore, ADF aircraft, personnel to assist evacuation of hundreds from flooded NT remote communities, Rajwinder Singh expected to be charged with murder of Cairns woman Toyah Cordingley tonight, police say, Watch Australia's economic challenges unfold in five graphs, 'Weight of the dead on my shoulders': Academic breaks down at gay hate deaths inquiry, Inquest into teen's tragic death from infected toenail resumes, More complaints about Broken Hill Hospital following patient deaths, Inquest begins into teen's death from infected toenail, Outside her tent, next to a popular city walking track, homeless Tasha is past caring what people think. Advertisement Ad Ms Edwards said it is a NSW Health policy that hospitals check vital signs before discharging a patient from emergency. For that (new) triage process to work, there needs to be more staff and more resources to prevent any more tragic circumstances, the nurse said. This service may include material from Agence France-Presse (AFP), APTN, Reuters, AAP, CNN and the BBC World Service which is copyright and cannot be reproduced. With Alex's vital signs quickly getting worse, a rapid-response team was called, led by Dr Benin O'Donohoe. The inquest heard Mr Braes had an ingrown toenail in August 2017 that was successfully treated with antibiotics. It recently handed down 44 recommendations to boost the rural medical workforce and improve the standard of care. Findings and upcoming inquests - Coroners Court Inquest findings (since 2004) as well as non-inquest public interest matters (since 2012) are available below. "Was there a general feeling it compromised patient safety?" A New South Wales regional hospital where a teenager was sent home three times days before his death is still not safe due to staff shortages, a coroner has heard. One matter consistently raised throughout the week's proceedings was a business rule then in place at Broken Hill Hospital when Mr Braes presented there four times in September 2017. Labor set a superannuation trap and Dutton immediatelytook the bait, Here's what the super tax changes might mean for you, NT Labor candidate confirms involvement in fatal car crash that led to conviction of driving without due care, Freya is one of 15,000 Australians who must find a new life-saving medication or pay a much higher price, Man who murdered Jay Brogden convicted of contempt of court, Live: Australia loses first wicket on day two but still on top in Indore. Experts remain divided whether Alex had the type of GAS known as necrotising fasciitis, a flesh-eating bacteria which results in the rapid death of the bodys soft tissue. Mr McLean says by this stage Alex's third presentation alarm bells should have been ringing. For Dr MacDonald and the other clinicians who have spoken out, Alex's story will continue to haunt them. Like that day, she said the nurses were still often very busy and under an awful lot of pressure. Were sorry, this feature is currently unavailable. Can pain kill you?: Teens final words after he was turned away from NSW hospital. Ms Kelly today told the court she was on a break when Mr Braes represented at the hospital with his dad on September 21. Alex Braes, 18, died at Sydney's Royal Prince . Alex Braes, 18, died at the Royal Prince Alfred Hospital in . Sign up to receive an email with the top stories from Guardian Australia every morning. 7 (PDF, 113.1 KB), Coffs Harbour Local Court, 2-16 Beryl St, Coffs Harbour 2450, Before her Honour Magistrate Forbes, Deputy State Coroner, Forensic Medicine and Coroners Court Complex, 1A Main Ave, Lidcombe, Before his Honour Magistrate Lee, Deputy State Coroner, Forensic and Coroners Court Complex, 1A Main Ave, Lidcombe, Inquest into the Death of A.W. Labor set a superannuation trap and Dutton immediatelytook the bait, Here's what the super tax changes might mean for you, NT Labor candidate confirms involvement in fatal car crash that led to conviction of driving without due care, Freya is one of 15,000 Australians who must find a new life-saving medication or pay a much higher price, Man who murdered Jay Brogden convicted of contempt of court, Live: Australia loses first wicket on day two but still on top in Indore. Alex Braes, 18, died at Sydney's Royal Prince Alfred Hospital about 46 hours after limping into Broken Hill Base Hospital at 3am on September 20, 2017. Alex Braes, 18, died of multi-organ failure caused by sepsis. Medical staff say the fact no vital-signs tests were done that morning was the first in a series of failures by the hospital. "Yes, it would've been very helpful to have such contact with a big centre ICU," he replied, "That you get expertise as early as possible involved.". Broken Hill teen Alex Braes died in 2017. Alex arrived at Broken Hill Hospital's emergency department. "It is entirely possible that Alex had a severe cellulitis without reaching the threshold of necrotising fasciitis, which led to his bloodstream infection and sepsis.". He told the inquest though, that on the balance of probabilities, Alex most likely had necrotising fasciitis. Alex was now in toxic shock from a deadly, flesh-eating disease known as necrotising fasciitis. She described the death of the fitter and turner as almost unbearable to imagine for the family. This would have left the state's Far West region without a pilot or plane, according to the retrieval specialist. Browse for your location and find more local ABC News and information. Eighteen-year-old Alex Braes' knee was so painful, he asked his father to take him to Broken Hill Hospital. This action will also remove this member from your connections and send a report to the site admin. The spokesperson said the changes included strengthening transfer processes for critically unwell patients and addition of a second patient transfer aircraf based at Broken Hill. All the stuff he wanted to do, theyre all memories now.. A shortage of resources was one factor contributing to Mr Braes' death, Ms Kelly said. There was an "extraordinary lack" of progress between NSW Health and SA Health in establishing a formalized cross-border arrangement to transfer critically-ill patients from Broken Hill to Adelaide, Ryan said. Mr Braes also recalled Alexs vital signs, including his temperature and pulse, were not checked each time he attended hospital. Follow our Australia news live blog for the latest updates, serious gaps in healthcare in rural and regional areas. It was not until his fourth and final presentationmore than 30 hours laterthat vital observations were taken of him and a suspected toenailinfection was identified. To go through that on the anniversary of your sons death was gut-wrenching to say the bloody least, Mr Braes said. Kelly said she had raised staffing levels with hospital management but was led to believe the departments patient numbers did not warrant an extra nurse. However, the rule did not comply with NSW Health policy, was "potentially dangerous" and should not have been introduced, according to Ryan. Get the best investigative journalism, delivered to your inbox. Alex was told to go home and come back later that morning for an ultrasound. Former Broken Hill obstetrician Dr Simon Stewart-Rattray told Four Corners the failure to do vital-signs observations was "indefensible". Doctor leading team in NSW's far west 'deeply shocked' to learn 18-year-old died after being evacuated to Sydney Broken Hill doctor who led team working on 18-year-old Alex Braes teenager has. Browse for your location and find more local ABC News and information. The day's hearing also heard from DrDevinda Arangala, who reviewed Alex during the early hours of September 20, 2017, when the teenager first presented to the hospital with a sore knee. the NSW member for Barwon said. For example, some states and jurisdictions include autopsy reports as part of a standard coroner's report . The nearest tertiary hospital to Broken Hill was Royal Adelaide, which although in another state, had a much closer flying time than Sydney. Please note: In a statement, the FarWest Local Health District said it expressedits deepest sympathies to the family of Mr Braes and acknowledgedthe heartache caused by his death. Alex Braes, from Broken Hill died from a deadly flesh-eating diseases in 2017 Inquest into the 18-year-old's sudden death reveals doctors missed vital signs Young man complained of severe pain. Deputy State Coroner Magistrate, Elizabeth Ryan, asked Ms Murphy whether the rule resulted in fewer cases of vital signs being taken and recorded at the hospital once implemented. Download the ABC News app for all the latest. Alex's father wheeled him into the emergency department and a nurse observed him through a window and asked him to wait. (Supplied) Friday, 12.50am More than 14 hours after his father had first called an ambulance, Alex finally arrived at RPA Sydney a hospital that could actually treat him. Copyright IBTimes 2023. Key points: The Coroner's Court hears evidence about Alex Braes' medical treatment in his final 12 hours We acknowledge Aboriginal and Torres Strait Islander peoples as the First Australians and Traditional Custodians of the lands where we live, learn, and work. Several changes had occurred to the patient triage process at Broken Hill base hospitals emergency department since the September 2017 death of Alex Braes, the registered nurse Kristy Kelly told the NSW coroners court on Wednesday. In October 2021, 27-year-old Callum Jones was peacefully walking his dog when he sprained his ankle by slipping on a wooden bridge. She has recommended that the states' respective health departments continue discussions for formalizing that arrangement and for the matter to be escalated to the NSW Health Secretary if it fails to be in place within a year. Counsel Assisting the coronial Inquest Emma Sullivan asked registered nurse Caroline Anderson, who attended to Alex on his first presentation, whether the rule had applied to him at that presentation. An inquest into how a Broken Hill teenager diedfrom an infected toenailhas heard his condition deteriorated rapidly in his final hours. "I was aware that many of the staff felt that it affected the way they triaged and potentially could affect the accuracy of their triages," replied Ms Kelly. abc.net.au/news/alex-braes-inquest-findings-health-systems-criticised/101109422 The Deputy State Coroner has criticised a regional hospital's treatment of a boy who was repeatedly sent home before dying from sepsis. 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