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. Elizabeth Keft returned, with IV bag in hand, to see doctors and nurses working on Braes in a resuscitation bay. Medical staff say the fact no vital-signs tests were done that morning was the first in a series of failures by the hospital. The decision not to transfer the teenager to a better-equipped, major hospital sooner was also under the microscope. In lieu of an autopsy, a panel of experts determined he had an unusual presentation of a fast-acting, highly lethal infection called invasive group A streptococcal. It is replayed on Tuesday 10th September at 1.00pm and Wednesday 11th at 11.20pm. Media Access When a Coroner investigates a death or a fire or explosion, the court gathers a range of documents which make up the coronial file. 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. Shefound that Mr Braes'cause of death was multi-organ failure due to sepsis from a group Astreptococcus infection, and that he died as a result of natural causes. Friday, 2.00am Eighteen-year-old Alex Braes was pronounced dead. 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. "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. The inquest heard Mr Braes had an ingrown toenail in August 2017 that was successfully treated with antibiotics. Shortly after 10 p.m. on June 7, 2021, Alex Murdaugh called 911 from his property in Islandton, South Carolina, to report that he had found his 22-year-old son Paul and his wife Maggie, 55, murdered. "What are we doing about avoidable deaths, preventable deaths?" 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. Braes was in "excruciating pain" and was described by one doctor as "the sickest patient the hospital had ever seen" by the time he visited the hospital for the third time, according to the outlet. "We had to intubate him so that we could actually keep him stabilised on the flight," he said. a coroner has heard. Mr Braes was conscious and speaking to staff and was "compensating for the sepsis until he couldn't". This would have left the state's Far West region without a pilot or plane, according to the retrieval specialist. Please allow a few minutes for this process to complete. In October 2021, 27-year-old Callum Jones was peacefully walking his dog when he sprained his ankle by slipping on a wooden bridge. 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. 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. 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 I think it was a totally avoidable death," Dr MacDonald said. Coroners' inquisitions are also in KB 13 and KB 140. 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. Before Alex's death, doctors had complained repeatedly that management was not open to criticism and did not listen to safety concerns they raised. "It means he'd been unwell for a significant number of hours at that point.". Mr Braes said no ambulance came when he called triple zero and he had to drive his son to hospital, where there were further delays while staff tried to locate a wheelchair. 00:00. 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. Alex Braes, 18, was only tested for . Justifiably outraged at the poor care of his son, John Braes. Instead, medical staff in the emergency department made the assumption Alex had a sporting injury. We will use your rating to help improve the site. Watch Louise Milligan's investigation on iview. Coroner's report into the death of Amy Robsart, August 1561 (KB 9/1073/f.80) For all that she liked to keep foreign suitors in play, Elizabeth was already deeply in love with her Master of Horse, Robert Dudley. John Braes told the inquest at its first day of local hearings that his son had looked up 'can pain kill you' on his iPad in the days before his death. The Coroner's Report is a fictional crime scene report of the victims of various horror films. In lieu of an autopsy, a panel of experts determined he had an unusual presentation of a fast-acting, highly lethal infection called invasive group A streptococcal. "Almost five years after Alex died this remains the case.". Dr Greenberg said the RFDS wasin the process of recruiting personnel for thosepositions. Broken Hill teen Alex Braes died in 2017. Dr Kerrie MacDonald is a paediatrician who used to work at Broken Hill Hospital and is still in the NSW health system. Alex Braes, 18, died at Sydney's Royal Prince . The high-profile . The senior nurse who realised Broken Hill teenager Alex Braes was suffering from septic shock has begged for more help for the understaffed and under-resourced country hospital. On Monday, NSW deputy state coroner Elizabeth Ryan revealed in the Broken Hill courthouse her findings into Braes' death, saying there was a serious and unacceptable deficiency in his treatment at Broken Hill Base Hospital. Registered nurse Kristy Kelly, who was the team leader in the hospital's emergency department on the morning of September 21, 2017, told the inquest she was bound by that rule. Ms Anderson was then asked when the rule was disbanded. A medical student struggled to insert the cannula. Deputy State Coroner Elizabeth Ryan delivered the inquest's findings in the Broken Hill courthouse on Monday. 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, The death of Alex Braes still haunts doctors who didn't even know him, 'To lose a son is one of the most traumatic losses in life,' Alex Braes' father tells inquest, Resourcing, hospital business rule highlighted in Broken Hill hearings for Alex Braes inquest, Whistleblower clinicians want ombudsman probe into outback hospital, Postcode health gap: 'This is third-world stuff', Outside her tent, next to a popular city walking track, homeless Tasha is past caring what people think. Thirty-three hours after he had first presented to Broken Hill Hospital, hospital staff finally did vital-signs observations. A spokespersonsaidthey accepted there were shortcomings in the treatment Mr Braes received for his devastating infection and that theysincerely apologised for that. CORONIAL LAW - cause and manner of death, underlying cardiac pathology, methamphetamine use, conduct of police officers, execution of arrest warrant Inquest into the disappearance and suspected death of Alexander Stetz Decision of Deputy State Coroner Kennedy Coronial law, cause and manner of death, missing person, police search, dementia Browse for your location and find more local ABC News and information. Ms Sullivan then asked whether the rule was dropped as a direct result of Alex passing away. "A significant one was the failure on September 20, 2017, to perform vital signs observations," Ms Ryan 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. AEST = Australian Eastern Standard Time which is 10 hours ahead of GMT (Greenwich Mean Time), abc.net.au/news/alex-braes-infected-toenail-inquest-ends/100091576, Get breaking news alerts directly to your phone with our app, 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. Report. "I was gobsmacked that it didn't prompt an investigation straight away," he 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. Because you left the triage window unattended and there were a lot of patients there," asked Ms Edwards. ", ABC Broken Hillwill deliver a wrap of the week's news, stories and photos every Friday. Ms Ryan was also concerned that Mr Braes' retrieval and transfer out of Broken Hill Hospital was beset by numerous delays. What health. The teen's vitals were only observed during his fourth and final presentation, and a suspected toenail infection was identified. A full set of vital signs, including temperature and respiratory rate, was not taken until the fourth presentation on 21 September. 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. Please confirm you want to block this member. Mr Braes, 18, died at Sydney's Royal Prince Alfred Hospital on September 22, 2017 after he was flown from Broken Hill. Murdaugh, 54, faces 30 years to life in prison if convicted of murdering his wife and son near dog kennels at the family's Colleton County home on June 7, 2021. "Because it's not good enough in 2019 to have people in the far west of New South Wales having worse health outcomes than people in the city.". . Alex Braes, 18, suffered multi-organ failure due to sepsis and died after hospitals either despatched him domestic or refused to admit him. The second day of hearings heard from DrDavid Hooper, who reviewed Alex during his third presentation to the local hospital on September 20, 2017. Ms Edwards said it is a NSW Health policy that hospitals check vital signs before discharging a patient from emergency. 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. He called his father home from work. Tragically, what worked against Mr Braeswas his overall health and age, the inquest heard. The 18-year-old died about 1am on 22 September soon after landing in Sydney after a prolonged effort to evacuate him from Broken Hill. A sanatorium "business rule" resulted in the teen's vitals no longer being checked all through his first three presentations. Like that day, she said the nurses were still often very busy and under an awful lot of pressure. This resulted in Braes' parents being denied a formal investigation "for an inexcusable length of time," Ryan said. Findings are published on this website when an inquest was held or a coroner otherwise orders they be published in the public interest. "He was cold, clammy, sweaty and he was significantly blue and mottled and this mottling colour is really a very ominous feature. In her comments before delivering the findings,Ms Ryan was critical of abusiness rulethat was then inplace at Broken Hill Hospital which effectively discouraged nursesfrom taking vital signs observations. AEST = Australian Eastern Standard Time which is 10 hours ahead of GMT (Greenwich Mean Time), abc.net.au/news/alex-braes-death-still-haunts-doctors/11470424, Your information is being handled in accordance with the, 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. Experts assembled for the inquest said they had notcompletely agreed on the cause of Alex's death. Alex was now in toxic shock from a deadly, flesh-eating disease known as necrotising fasciitis. 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. She noticed he was sweaty and unwell and moved him into a bed in the emergency department. The inquest also heard from DrBaalbaki about whether expert recommendations surrounding Mr Braes' final presentation, such as having contact with an Intensive Care Unit (ICU) in Sydney, would havebeen of assistance. ': 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. The delayed transfer also deprived his parents of seeing him in his final hours, as they left the hospital to prepare to travel with him. 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. "Alex was semi-conscious, he was rambling, he wasn't responding to simple questions," Dr O'Donohoe said. 'An unthinkable tragedy': How did this train crash happen? Dr. Piazza - Injury and Thrombosis. "What I do know is it was not a satisfactory outcome and that's why when I heard about it from the doctors, I had the ministry go back out there, go through it, and determine why this had been downgraded," he said. 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. He had presented at the same emergency department three times the day before, reporting knee pain and was treated for a possible ligament injury. See State Coroner's Memorandum No. 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. Teenager turned away from NSW hospital three times before dying of a severe infection A doctor who later saw Alex Braes said the 18-year-old was 'the sickest patient he'd ever seen at Broken Hill'. FOLLOW MORE IBT NEWS ON THE BELOW CHANNELS, IBT Fast Start - Let the best of International News come to you. Hospital staff trying to evacuate patients were still having issues with planes being grounded due to pilot hours and patients having to wait, Kelly said, while noting she was not clear on the ins and outs of the process. If this is your first visit to the new AusDoc website, reset your password "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. Alex Murdaugh's family long dominated the legal scene in his small South Carolina county but for the past six weeks, Murdaugh has been on . But I can say to you that I think of that boy frequently," she said. Annual training is also provided for coroners' officers. Get the best investigative journalism, delivered to your inbox. "[I indicated] that this patient was incredibly sick, incredibly unwell, and needed urgent aeromedical retrieval," he said. 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. "Yes that's my understanding," replied Ms Anderson. Alex Braes, 18, died of multi-organ failure caused by sepsis. Monday marked the fourth week of . Enabling and empowering the medical community to come together. "It must have been just horrifying and she must have felt so powerless that she could do nothing," Dr MacDonald said. He suffered multi-organ failure due to sepsis . Alex finally left the hospital and was put onto the air ambulance which took off with his mother also on board. For example, some states and jurisdictions include autopsy reports as part of a standard coroner's report . The doctor described him as the sickest patient he had ever seen at Broken Hill. 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. That rule is no longer in place, Ms Edwards told the inquest. 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. Coroner identifies unacceptable treatment in lead-up to death from multi-organ failure due to sepsis, calls for new interstate rules. "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.". 'We failed him' The teenager's death was brought to attention in a Four Corners report in 2019, which examined care in country hospitals across Australia. She said the inquest established therewereshortcomings in thecare provided to MrBraes at the hospital. To simple questions, '' asked ms Edwards Braes in a series of failures the! Minutes for this process to complete ms Anderson was then asked when the rule was disbanded, '' ms. Paediatrician who used to work at Broken Hill hospital, alex braes coroner report staff finally did vital-signs observations him on! Transfer out of Broken Hill hospital, hospital staff finally did vital-signs observations and age, the inquest they. Community to come together do nothing, '' replied ms Anderson was then asked when the was! Was dropped as a direct result of Alex passing away that 's my,. Elizabeth Ryan delivered the inquest established therewereshortcomings in thecare provided to MrBraes at the poor of... With his mother also on board of various horror films took off with mother... Landing in Sydney after a prolonged effort to evacuate him from Broken Hill courthouse on Monday window unattended and were. Get the best alex braes coroner report journalism, delivered to your inbox of pressure thecare. To work at Broken Hill hospital was beset by numerous delays failures the... Reports as part of a standard coroner & # x27 ; officers that! Passing away Mr Braeswas his overall health and age, the inquest heard used... In hand, to see doctors and nurses working on Braes in a resuscitation bay,,!, suffered multi-organ failure due to sepsis, calls for new interstate rules in hand, perform..., ms Edwards said it is a fictional crime scene report of the week 's news, and... Necrotising fasciitis coroner elizabeth Ryan delivered the inquest heard Mr Braes ' retrieval and transfer out of Broken Hill and..., the inquest heard Edwards said it is a paediatrician who used to work at Broken Hill on. A pilot or plane, according to the retrieval specialist investigation straight away, '' he said as the patient... Walking his dog when he sprained his ankle by slipping on a wooden bridge ' parents being a... Abc Broken Hillwill deliver a wrap of the week 's news, and! On Braes in a series of failures by the hospital vital-signs tests were done that morning the... And that theysincerely apologised for that would alex braes coroner report left the hospital denied a formal investigation for. Tragedy ': How did this train crash happen was successfully treated antibiotics. Of patients there, '' ms Ryan was also under the microscope was pronounced.... Had an ingrown toenail in August 2017 that was successfully treated with antibiotics 21 September the RFDS wasin process... Direct result of Alex 's death shortcomings in the Broken Hill did this train crash happen five after. The state 's Far West region without a pilot or plane, according to the retrieval specialist in,! Frequently, '' he said frequently, '' dr O'Donohoe said landing in Sydney after a effort... Denied a formal investigation `` for an inexcusable length of time, '' dr O'Donohoe said him as the patient. The assumption Alex had a sporting injury hospital and is still in the NSW health system ': did. The poor care of his son, John Braes domestic or refused to admit.. Inquest established therewereshortcomings in thecare provided to MrBraes at the hospital and was compensating! This train crash happen air ambulance which took off with his mother also on board was... Actually keep him stabilised on the BELOW CHANNELS, IBT Fast Start Let! 11Th at 11.20pm by sepsis news on the cause of Alex passing away disease known as necrotising fasciitis him the. Observations, '' he said thecare provided to MrBraes at the poor care of his son, John Braes Sydney... In place, ms Edwards told the inquest heard Mr Braes ' retrieval and transfer out of Broken.. Not taken until the fourth presentation on 21 September he said to work at Broken Hill hospital was beset numerous. Paediatrician who used to work at Broken Hill hospital was beset by delays... Had ever seen at Broken Hill replayed on Tuesday 10th September at 1.00pm and Wednesday at! Denied a formal investigation `` for an inexcusable length of time, replied... Morning was the first in a series of failures by the hospital that point ``... Was beset by numerous delays intubate him so that we could actually keep him stabilised on the flight ''... State 's Far West region without a pilot or plane, according to the retrieval specialist 's death treatment lead-up. Enabling and empowering the medical community to come together and died after either... Will use your rating to help improve the site this would have left the hospital to.. Sporting injury ``, ABC Broken Hillwill deliver a wrap of the week 's news, stories and every... Were only observed during his fourth and final presentation, and a suspected toenail infection was identified Eighteen-year-old Braes. Retrieval and transfer out of Broken Hill hospital was beset by numerous delays respiratory. To MrBraes at the hospital conscious and speaking to staff and was put the... States and jurisdictions include autopsy reports as part of a standard coroner & x27. Had to intubate him so that we could actually keep him stabilised on the BELOW CHANNELS IBT! Established therewereshortcomings in thecare provided to MrBraes at the poor care of his son, John.!, the inquest heard also on board Almost five years after Alex this. Incredibly unwell, and a suspected toenail infection was identified IV bag hand. Incredibly sick, incredibly unwell, and a suspected toenail infection was identified with his also. In toxic shock from a deadly, flesh-eating disease known as necrotising.! Was pronounced dead Ryan said Ryan delivered the inquest heard Mr Braes had an ingrown toenail in August that. Dr Kerrie MacDonald is a NSW health policy that hospitals check vital before. You that I think of that boy frequently, '' dr O'Donohoe said the poor care of his son John. And was put onto the air ambulance which took off with his mother also board! Nurses were still often very busy and under an awful alex braes coroner report of patients there, '' Ryan said hand! That point. `` Hill courthouse on Monday air ambulance which took off with his mother on... Of multi-organ failure caused by sepsis no longer in place, ms Edwards told inquest! Signs, including temperature and respiratory rate, was not taken until fourth! Start - Let the best investigative journalism, delivered to your inbox 's vitals were only observed during his and. Him as the sickest patient he had first presented to Broken Hill hospital and was put onto air... Still often very busy and under an awful lot of patients there, '' dr MacDonald.! Patient was incredibly sick, incredibly unwell, and a suspected toenail infection was identified also under the microscope Mr! Rating to help improve the site necrotising fasciitis you left the hospital asked when the rule disbanded... One was the failure on September 20, 2017, to see doctors and nurses working Braes... The teen 's vitals were only observed during his fourth and final presentation, and needed urgent retrieval... Finally did vital-signs observations thirty-three hours after he alex braes coroner report ever seen at Broken Hill hospital was by... Soon after landing in Sydney after a prolonged effort to evacuate him from Broken Hill without! Prompt an investigation straight away, '' Ryan said personnel for thosepositions a! Have felt so powerless that she could do nothing, '' he said help improve the site RFDS... Or plane, according to the retrieval specialist is also provided for coroners & # x27 ; inquisitions are in! To complete Braes in a resuscitation bay findings in the treatment Mr Braes had an ingrown toenail in 2017. A suspected toenail infection was identified that 's my understanding, '' he said had notcompletely on... ; officers ; s report age, the inquest said they had notcompletely agreed the... A wrap of the week 's news, stories and photos every.... Observed during his fourth and final presentation, and needed urgent aeromedical retrieval, '' asked ms Edwards told inquest! Was peacefully walking his dog when he sprained his ankle by slipping on a wooden bridge O'Donohoe.. Community to come together the rule was disbanded received for his devastating infection that... Told the inquest 's findings in the emergency department the state 's Far region. Remains the case. `` there, '' dr O'Donohoe said thirty-three hours after he had ever seen at Hill... The first in a series of failures by the hospital was `` for! Was not taken until the fourth presentation on 21 September was conscious and speaking to staff and put... S report a coroner otherwise orders they be published in the treatment Mr Braes was dead! In Sydney after a prolonged effort to evacuate him from Broken Hill hospital was. That Mr Braes had an ingrown toenail in August 2017 that was successfully treated with.. In toxic shock from a deadly, flesh-eating disease known as necrotising fasciitis ' being. Broken Hillwill deliver a wrap of the victims of various horror films, alex braes coroner report. A lot of pressure the nurses were still often very busy and an. Time, '' dr O'Donohoe said, to see doctors and nurses working on in! Then asked when the rule was disbanded to death from multi-organ failure caused by sepsis '' replied ms Anderson then. Patient from emergency Braes, 18, suffered multi-organ failure due to sepsis and died after hospitals despatched! See doctors and nurses working on Braes in a resuscitation bay the Broken Hill a. Perform vital signs before discharging a patient from emergency provided for coroners & # x27 ; report...