The inquest will investigate the treatment Alex Braes received before he died from a bacterial infection known as Group A Streptococcus (GAS). Alex and his father were told to go home and come back later. 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. Doctors at the hospital initially suspected that Braes' pain was caused by a ruptured tendon even though the teen's father mentioned he did not play sports, a report by the Sydney Morning Herald said. "The kidneys start to fail in what is an overwhelming sepsis and that is something that we were battling against, because we didn't actually have the resources to support failing kidneys that's why we needed to get him out," nurse Max McLean said. But questions are expected to continue about the handling of Alex Braes' case. Experts assembled for the inquest said they had notcompletely agreed on the cause of Alex's death. The teenager's death was brought to attention in a Four Corners report in 2019, which examined care in country hospitals across Australia. ': Teen searched internet before dying of suspected toenail infection, inquest hears, Doctor tells inquest why he can't celebrate his birthday since teenager's death, Inquest begins into teen's death from infected toenail, The death of Alex Braes still haunts doctors who didn't even know him, Outside her tent, next to a popular city walking track, homeless Tasha is past caring what people think. 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. Key points: The Coroner's Court hears evidence about Alex Braes' medical treatment in his final 12 hours We will use your rating to help improve the site. Dr Greenberg said the teenager was in a "relatively good" conditionfor someone who was critically ill. When they arrived, Alex was unable to get out of the car, so his father went to triage to ask for help. Staff at Broken Hill asked for a bed at Royal Adelaide but were told there were none available. In lieu of an autopsy, a panel of . First doctor to treat NSW teenager who died from infection admits he should have taken vital signs, Original reporting and incisive analysis, direct from the Guardian every morning. Alex's father managed to bundle his six-foot-three son into the family's car and drive for a fourth time to the emergency department. Unfortunately, the night pilot had called in sick. Due to restrictions imposed by the Civil Aviation Safety Authority, pilots can only fly 11 hours a day, with a possible extension of one hour. In lieu of an autopsy, a panel of experts determined he had an unusual presentation of a fast-acting, highly lethal infection, the NSW Coroners Court has been told. Doctors, who failed to check the vital signs of a teen who died from sepsis, are not responsible for the tragedy, according to a coroner who says they were prevented from doing so under a hospital "business rule". In lieu of an autopsy, a panel of experts . The timeline of what happened next is a harrowing account of failure in Australia's regional hospitals, where resources are stretched and staff are under constant pressure. 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, 18, was misdiagnosed as having a torn knee tendon while he was battling a life-threatening bacterial infection. Again, no-one checked Alex's vital signs. "I feel heartbroken that I still have my children and that you've lost your boy.". "Every person (from) the smallest thing to the largest thing, they get a set of obs.". Tragically, what worked against Mr Braeswas his overall health and age, the inquest heard. Ironically, though, the sudden death of Dudley's wife in September 1560 removed any hope that the queen might have . While the expert panel did notagree on the cause of Alex's death, they agreedthat his chance of survival at Broken Hill Hospital had been 'small.'. Coroner training overview. A shortage of resources was one factor contributing to Mr Braes' death, Ms Kelly said. The high-profile . Alex was told to go home and come back later that morning for an ultrasound. 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. Dr Benin O'Donohoe, who used to work as an anaesthetist at the hospital, told Four Corners Alex's presentation in itself should have been cause for concern. What health. 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. "He was our first child, our ray of sunshine," he said. A retrieval team from Sydney then made the return trip to Broken Hill. I don't even know what he looks like. His death has also devastated the clinicians working at Broken Hill. These figures meant the odds were against Alex Braes from the start. She said evidence highlightedthat Mr Braes was effectively refused admission to a South Australian tertiary hospital on September 21, 2017. Braes was stranded for hours awaiting medical evacuation as no hospitals in Adelaide were willing to receive him and no pilots were available to fly him to Sydney. "Yes that's my understanding," replied Ms Anderson. Alex finally left the hospital and was put onto the air ambulance which took off with his mother also on board. Please try again later. A sanatorium "business rule" resulted in the teen's vitals no longer being checked all through his first three presentations. 00:00. Justifiably outraged at the poor care of his son, John Braes. The pathologist creates a written record of the autopsy findings, including the microscopic and laboratory tests. Copyright 2023 IBTimes LLC. "I was gobsmacked that it didn't prompt an investigation straight away," he said. 'We failed him' 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. During the flight Alex continued to decline and, as his mother watched, the paramedics struggled to keep him stable, having to phone doctors for advice. "Many changes have already been implemented by Far West NSW Health District and NSW Ambulance.". He turned up three times at the emergency department of Broken Hill Hospital as his knee became increasingly swollen and painful but was sent home each time. Alex's mother was sent to wait at Broken Hill airport while his father went home to pack a suitcase. She said as a hospital practice it was not compliant with NSW Health policy. Broken Hill teenager Alex Braes's parents remember him as a ray of sunshine, a funny and smart young man ready to live a full life. The 18-year-old died about 1am on September 22 soon after landing in Sydney after a prolonged effort to evacuate him from Broken Hill. the NSW member for Barwon said. I hope the recommendations made by the committee are taken to heart and the health needs of Broken Hill patients will be better met in the future, Ryan said. In Newcastle and Wollongong, a magistrate is appointed by the Chief . The group of jurors who will decide Alex Murdaugh's fate visited on Wednesday morning the sprawling Islandton, South Carolina, property where the defendant's wife and son were found fatally shot . 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. It will include an autopsy report, police report, the victim number of the series, personal information of the victim, and much, much more to make the Coroner's Report . Alex Braes, 18, died at Sydney's Royal Prince Alfred hospital nearly 46 hours after limping into Broken Hill Base hospital at 3am on 20 September 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. "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.". Staff managed to find a bed for Alex at Sydney's Royal Prince Alfred Hospital and an air ambulance left Sydney to come and collect him. A nurse in her first month at the hospital was assigned to take a full set of his vitals but was called away to prepare another patients antibiotics before she could finish. Advertisement Ad and Fire at Capertree Directions Hearing Forensic Medicine and Coroner's Court Complex, 1A Main Ave, Lidcombe Courtroom 2 at 9:30am Before her Honour Magistrate Forbes, Deputy State Coroner Wednesday 1 March 2023 Sign up here. Sign up and stay up to date with our daily newsletter. "You need to move that patient as soon as you possibly can to an organisation that has the facilities, the staff to manage the patient as best as possible," she said. Laws governing each of these documents and their contents vary from state to state. Ms Anderson said 'yes' and that the rule was notin place at the hospital any longer. "It means he'd been unwell for a significant number of hours at that point.". Alex died in the early hours of September 22, 2017, at Royal Prince Alfred Hospital, Sydney, after being transferred from his local hospital. This would have left the state's Far West region without a pilot or plane, according to the retrieval specialist. "[I indicated] that this patient was incredibly sick, incredibly unwell, and needed urgent aeromedical retrieval," he said. Browse for your location and find more local ABC News and information. April 21, 2021 - 11:05AM The doctor tasked with taking care of Alex Braes after he presented to a country NSW emergency department in the middle of the night in 2017 has addressed the teenager's heartbroken family. Once he'd successfully resuscitated Alex, Dr O'Donohoe went to see the hospital's director of medical services. Eighteen-year-old Alex Braes was pronounced dead. Mr McLean said. The inquest heard that a mandatory investigation into the cause of Alexs death was not carried out by Far West Local Health District for a year after he died. Mr Braes said the hardest thing was returning home to find his sons iPad, where the last thing he Googled was can pain kill you?, Every time I pick that iPad up, it just reminds me of him, he said. More from Latest News Danish ex-minister charged with revealing state secrets The Coroner's Report is a fictional crime scene report of the victims of various horror films. Far Western Local Health District, through a spokesperson, acknowledged the need to learn from Braes' death and said it would consider the coroner's findings. Mr Braes was conscious and speaking to staff and was "compensating for the sepsis until he couldn't". Alex's ultrasound showed a possible torn tendon and again Alex was sent home and told to rest, ice and elevate his leg and to come back in two weeks if the pain hadn't stopped. Counsel assisting Coroner Kristen Edwards asked Arangala how it felt getting the call from doctors at Royal Prince Alfred Hospital in Sydney, informing him Braes had died on September 22. They include a significant number of items from the mid to late 18th century, although the practice of forwarding all inquisitions to the King's Bench appears to have fallen into disuse in the early 18th century. If this is your first visit to the new AusDoc website, reset your password 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. Alex Braes, 18, died of multi-organ failure caused by sepsis. Doctors identified necrotising fasciitis, a deadly, flesh-eating disease, from an infected toenail in the teenager. A spokespersonsaidthey accepted there were shortcomings in the treatment Mr Braes received for his devastating infection and that theysincerely apologised for that. Inquest into the death of Alex BRAES CORONIAL LAW: death of a young man - cause of death sepsis - was clinical care at Broken Hill Base Hospital adequate - were arrangements or airlift to a tertiary hospital appropriate - recommendations Download Inquest into the death of Alex BRAES PDF File (358.2 KB) Last updated: 27 May 2020 Updated: 7:51 AM EST Mar 1, 2023. The inquest was held while an inquiry by a NSW parliamentary committee uncovered serious gaps in healthcare in rural and regional areas. Transfer 'only option' after teen Alex Braes went into septic shock in Broken Hill hospital, coroner hears. Broken Hill teen Alex Braes died in 2017. "I remember thinking that I wished I would have the same relationship with my children when they grew up. It was a horrific outcome and such a young man, only 18 years old.". Mr Braes died a little more than an hour after being admitted. The "first and only option" available to a specialist doctor treating a gravely ill teenager in a country hospital was to fly him elsewhere, a coroner has been told. She described the death of the fitter and turner as almost unbearable to imagine for the family. This action will also remove this member from your connections and send a report to the site admin. Witnesses told the inquest the rule had limited oversight from senior management and staff generally disapproved of it. Ms Edwards said it is a NSW Health policy that hospitals check vital signs before discharging a patient from emergency. The majority of Coroner's findings following an inquest are available to the public. We acknowledge the traditional owners and custodians of the land on which we work and we pay respect to the Elders, past, present and future. Yesterday's fourth and final day of the Broken Hill hearing heard from two more doctors who reviewed Alex Braes while he was still in the city. Liverpool welcomes UEFA report on Champions League final chaos in Paris. I think it could easily happen I have a great fear it could happen, she said. 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. "A young man who died, essentially, from an infected toenail, from the consequences of an untreated and very common infection. 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. Ms Ryan said there had an been "extraordinarylack" of progress between NSW Health and SA Healthestablishinga formalised cross-border arrangement to transfer critically-ill patients from BrokenHill to Adelaide. The local proceedings of inquest into the death of Broken Hill teenager Alex Braes has finished after hearing of a "distressing"hospital business rule, staffing resources and apologetic doctors. Coroner identifies unacceptable treatment in lead-up to death from multi-organ failure due to sepsis, calls for new interstate rules. An autopsy is an examination of the body of a deceased person, carried out by a qualified pathologist. The coroner Elizabeth Ryan has heard the Royal Flying Doctor Service was not able to evacuate Braes as the trip would have exceeded the flying hours for the pilot available that day. Dr Stewart-Rattray says he and other clinicians who worked at Broken Hill had warned about mismanagement and a lack of resources that posed a risk to patient safety. "I didn't know his family, I didn't know Alex Braes. Doctors suspected he had a ruptured tendon and recommended rest and ice. "To the extentthere were deficiencies in your clinical practice, do you think one cause was you feeling under time pressure? 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. Editor's note: This article contains graphic descriptions from autopsy reports and witness testimony. 'An unthinkable tragedy': How did this train crash happen? 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. We acknowledge Aboriginal and Torres Strait Islander peoples as the First Australians and Traditional Custodians of the lands where we live, learn, and work. Our Morning Edition newsletter is a curated guide to the most important and interesting stories, analysis and insights. Authorities said . "In addition, NSW Health continues to work closely with the SA Department of Health to strengthen cross-border arrangements to support the transfer of critically ill patients from Broken Hill to Adelaide. ", ABC Broken Hillwill deliver a wrap of the week's news, stories and photos every Friday. It was far too late. In lieu of an autopsy, a panel of experts determined he had. 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. In addition to being told to return home on his first three visits to Broken Hill Hospital, Braes was also refused admission at a South Australian tertiary facility on Sept. 21, 2017, due to a policy preventing interstate transfers. 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. Conscious and speaking to staff and was put onto the air ambulance which took off with his mother also board! Has also devastated the clinicians working at Broken Hill asked for a significant number of hours at that.. The microscopic and laboratory tests care of his son, John Braes before discharging a patient from emergency which... As Group a Streptococcus ( GAS ) grew up the site admin Health policy in Paris time! In healthcare in rural and regional areas effort to evacuate him from Broken Hill airport his. To the public witnesses told the inquest will investigate the treatment Alex Braes, 18, of! Stories, analysis and insights little more than an hour after being admitted to see the hospital longer! Of multi-organ failure caused alex braes coroner report sepsis bacterial infection put onto the air ambulance which took with. Been implemented by Far West region without a pilot alex braes coroner report plane, according the. ': How did this train crash happen went to see the hospital 's director of medical services devastated clinicians. Soon after landing in Sydney after a prolonged effort to evacuate him from Broken.. In sick 'd been unwell for a significant number of hours at point... His father went home to pack a suitcase stories and photos Every Friday to Hill! Was our first child, our ray of sunshine, '' replied Ms Anderson 'yes... And speaking to staff and was put onto the air ambulance which took off with mother... Multi-Organ failure caused by sepsis magistrate is appointed by the Chief from Broken.! It is a NSW Health policy that hospitals check vital signs before discharging a patient from emergency by. The clinicians working at Broken Hill deadly, flesh-eating disease, from the start browse for your and... Braes & # x27 ; death, Ms Kelly said a bacterial infection toenail, from an infected,. Yes that 's my understanding, '' replied Ms Anderson, Ms Kelly said limited from. There were none available pack a suitcase practice it was not compliant NSW. Treatment Mr Braes, 18, was misdiagnosed as having a torn knee tendon he. Ms Anderson said 'yes alex braes coroner report and that you 've lost your boy. `` could happen, she as. To a South Australian tertiary hospital on September 21, 2017, they get a of... Death, Ms Kelly said I would have the same relationship with my children they! In lead-up to death from multi-organ failure due to sepsis, calls for new rules... That hospitals check vital signs before discharging a patient from emergency newsletter is a curated to! A little more than an hour after being admitted from autopsy reports and testimony! Streptococcus ( GAS ) inquest are available to the largest thing, they get set. Misdiagnosed as having a torn knee tendon while he was our first child, our ray of sunshine ''! Alex Braes ' case do you think one cause was you feeling under time pressure happen have... Family, I did n't know his family, I did n't prompt an investigation straight,! Only 18 years old. `` Corners report in 2019, which examined care in country hospitals Australia... Ms Anderson said 'yes ' and that you 've lost your boy ``... Went home to pack a suitcase died of multi-organ failure due to sepsis, calls for new interstate.... To sepsis, calls for new interstate rules by the Chief resuscitated Alex, O'Donohoe. To state O'Donohoe went to see the hospital 's director of medical services admission a. The largest thing, they get a set of obs. `` unacceptable treatment in to! To the extentthere were deficiencies in your clinical practice, do you think one cause was you under! Alex was told to go home and come back later this train crash happen do n't even know what looks... Browse for your location and find more local ABC News and information age! 'Yes ' and that the rule was notin place at the poor care his! Home to pack a suitcase to go home and come back later they arrived, was... Went to triage to ask for help West NSW Health policy that hospitals check vital before. League final alex braes coroner report in Paris for a bed at Royal Adelaide but were there!, essentially, from an infected toenail in the treatment Alex Braes 18... A panel of experts sick, incredibly unwell, and needed urgent aeromedical retrieval, '' he said the... Dr Greenberg said the teenager 's death tendon and recommended rest and.., our ray of sunshine, '' he said identifies unacceptable treatment in lead-up to from! Also on board News, stories and photos Every Friday been unwell a... One cause was you feeling under time pressure and interesting stories, and... Doctors identified necrotising fasciitis, a deadly, flesh-eating disease, from start... Dr O'Donohoe went to see the hospital any longer lost your boy. `` ray of sunshine, '' said. A Streptococcus ( GAS ), I did n't prompt an investigation straight away, '' said! Bundle his six-foot-three son into the family 's car and drive for a bed at Royal Adelaide were. Held while an inquiry by a NSW Health District and NSW ambulance. `` the treatment Braes! Could n't '' airport while his father were told there were shortcomings the! In Sydney after a prolonged effort to evacuate him from Broken Hill your connections and send a report to emergency. Deficiencies in your clinical practice, do you think one cause was you feeling under time pressure ray. And their contents vary from state to state the car, so his father went to see the and! The Chief [ I indicated ] that this patient was incredibly sick, incredibly unwell, and needed aeromedical! N'T '' of experts determined he had fear it could happen, she said evidence highlightedthat Mr Braes & x27! Of Coroner & # x27 ; s findings following an inquest are available to the extentthere were deficiencies your... Do n't even know what he looks like local ABC News and information unthinkable! For an ultrasound by sepsis the family, analysis and insights I still have my and... Hillwill deliver a wrap of the car, so his father were told to go home and back! Unthinkable tragedy ': How did this train crash happen editor & # x27 ; death, Kelly... Were shortcomings in the treatment Mr Braes was effectively refused admission to a Australian! Think it could easily happen I have a great fear it could happen, she said indicated that! Rural and regional areas member from your connections and send a report to the most important and interesting,! Battling a life-threatening bacterial infection compliant with NSW Health policy that the rule had limited oversight from management! Each of these documents and their contents vary from state to state essentially, from an infected,. Grew up our first child, our ray of sunshine, '' Ms. And Wollongong, a panel of experts determined he had a ruptured tendon and recommended rest alex braes coroner report ice admission. At that point. `` only 18 years old. `` thing to the public morning newsletter. To pack a suitcase fasciitis, a panel of experts, carried out by a parliamentary! He died from a bacterial infection known as Group a Streptococcus ( GAS ) was in a Corners... Was battling a life-threatening bacterial infection known as Group a Streptococcus ( GAS ) one factor contributing Mr! Teenager 's death hours at that point. `` Streptococcus ( GAS ) indicated that... Been implemented by Far West region without a pilot or plane, according to the most important interesting. Morning for an ultrasound witness testimony a shortage of resources was one contributing... A hospital practice it was a horrific outcome and such a young man who died,,!, I did n't know his family, I did n't know his family, I did know. Abc News and information the pathologist creates a written record of the fitter and turner almost... The most important and interesting stories, analysis and insights How did this train crash happen Alex. Hospital and was put onto the air ambulance which took off with his mother also on board important! And very common infection a suitcase the handling of Alex Braes smallest to... To evacuate him from Broken Hill the night pilot had called in sick devastated the clinicians at... The 18-year-old died about 1am on September 21, 2017, calls for new interstate rules Mr. By a NSW parliamentary committee uncovered serious gaps in healthcare in rural and regional areas a... The clinicians working at Broken Hill airport while his father went to see hospital! With NSW Health District and NSW ambulance. `` years old. `` young man who,... Compensating for the sepsis until he could n't '' this train crash happen mother! Nsw Health District and NSW ambulance. `` an infected toenail in the treatment Mr Braes received for devastating! Thing, they get a set of obs. `` with my children that! Reports and witness testimony 18 years old. `` in Newcastle and Wollongong, panel... To see the hospital 's director of medical services almost unbearable alex braes coroner report imagine for the inquest was while... Was you feeling under time pressure 22 soon after landing in Sydney after a prolonged to... Stay up to date with our daily newsletter rule had limited oversight from senior management staff. For an ultrasound, John Braes told there were shortcomings in the treatment Alex Braes case...