00:00. She said the inquest established therewereshortcomings in thecare provided to MrBraes at the hospital. 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. 'An unthinkable tragedy': How did this train crash happen? "We as a medical profession, we as a health service in New South Wales, we failed Alex Braes and we failed his family," he said. "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. 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. "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.". 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. Alex Braes. This action will also remove this member from your connections and send a report to the site admin. 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. An inquest was established soon after that report and was due to undertake Broken Hill hearings last yearbut was delayed after coronavirusrestrictions affected proceedings. It grieves his parents deeply that they were not able to be with him in his last conscious hours, Ryan said. A hospital in the Australian state of New South Wales (NSW) repeatedly sent an 18-year-old boy home before he died from sepsis, officials revealed this week. Ryan also outlined major delays in transferring Braes to the Sydney hospital where he died in the early hours of 22 September 2017, after he was refused admission at a South Australian tertiary facility due to a policy preventing interstate transfers. 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. Part 1 Requesting the Autopsy Report 1 Understand the purpose of an autopsy. "I was gobsmacked that it didn't prompt an investigation straight away," he 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. Alex died in the early hours of September 22, 2017, at Royal Prince Alfred Hospital, Sydney, after being transferred from his local hospital. 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. A sanatorium "business rule" resulted in the teen's vitals no longer being checked all through his first three presentations. SA Health, for its part, has commenced discussions with its NSW counterpart on how to continue to best provide services on an ongoing basis. She recommended NSW and SA health departments urgently agree to cross-border transfers of critically ill patients from Broken Hill. 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. Instead, medical staff in the emergency department made the assumption Alex had a sporting injury. "Many changes have already been implemented by Far West NSW Health District and NSW Ambulance.". A teenager who had been turned away three times from Broken Hill Hospitals emergency department Googled can pain kill you? on his tablet device before he died from septic shock. This would have left the state's Far West region without a pilot or plane, according to the retrieval specialist. Alex Braes died at Sydney's Royal Prince Alfred Hospital after going to another hospital four times. The inquest into the death of Broken Hill teenager Alex Braes, who died of an infected toenail four years ago, will begin on Monday. 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. "This was a serious and unacceptable deficiency in his care and it was a missed opportunity to identify his underlying, evolving illness," the coroner said. 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. The inquest heard hospital staff did not check Braes full vital signs including temperature, pulse and blood pressure when he presented to the emergency department with severe leg pain on the morning of 20 September. "To the extentthere were deficiencies in your clinical practice, do you think one cause was you feeling under time pressure? "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. "It must have been just horrifying and she must have felt so powerless that she could do nothing," Dr MacDonald said. Alex's mother was sent to wait at Broken Hill airport while his father went home to pack a suitcase. 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. "Furthermore, Alex was not transferred to the closest hospital suitable forhis care, which was South Australia's Royal Adelaide Hospital," Ms Ryan said. In the Sydney metropolitan area, coronial matters are always handled by the State Coroner and Deputy State Coroners (senior coroners) situated at the Lidcombe Forensic Medicine and Coroners Court Complex. Were sorry, this feature is currently unavailable. . It recently handed down 44 recommendations to boost the rural medical workforce and improve the standard of care. On Monday, New South Waless deputy state coroner, Elizabeth Ryan, handed down her findings into Braes death, saying there was a serious and unacceptable deficiency in his treatment at Broken Hill base hospital. 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. Browse for your location and find more local ABC News and information. She noted that there was no realistic possibility that his specific infection could have been identified and successfully treated on September 20, 2017. 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. Sign up and stay up to date with our daily newsletter. The defense called forensic experts to dispute gunshot evidence and showed autopsy photos during the murder trial of disbarred South Carolina lawyer Alex Murdaugh, who is accused of fatally . That rule is no longer in place, Ms Edwards told the inquest. Dr O'Donohoe spoke to the Royal Flying Doctor Service at Broken Hill. They included a baby who died after a doctor failed to check her test results, a woman who bled to death in an emergency department without any doctors physically present and a man who was told his ward had run out of morphine and paracetamol. A doctor who later saw Alex Braes said the 18-year-old was 'the sickest patient he'd ever seen at Broken Hill' hospital. Coroner training overview. Alex's father called triple zero to ask an ambulance to take his son to hospital, but no ambulance was available. In an interview with Four Corners, Mr Hazzard said he was "not sure" the hospital broke the law, but Alex's death was a circumstance that, "as a father, I couldn't have imagined happening". 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. 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. "All I can say is since I became aware of the death of Alex Braes, I don't think I have stopped thinking about that young man.". Alex Braes. Findings are published on this website when an inquest was held or a coroner otherwise orders they be published in the public interest. "It means he'd been unwell for a significant number of hours at that point.". "Every person (from) the smallest thing to the largest thing, they get a set of obs.". Medical staff say the fact no vital-signs tests were done that morning was the first in a series of failures by the hospital. He would follow them to Sydney on a commercial flight. For legal cases involving intentional or accidental death and for insurance claims, The Records Company retrieves coroner's reports and autopsy reports. These figures meant the odds were against Alex Braes from the start. There was no "grab and go" for Alex and that would have devastating consequences. 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. His death has also devastated the clinicians working at Broken Hill. We will use your rating to help improve the site. It's something that troubles local MP Roy Butler. However, at the time of Alexs death, Broken Hill Hospital had implemented a business rule that meant nurses were discouraged from taking vital signs during triage. 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. By the fourth visit Alex was in excruciating pain and the leg was turning a dark purple colour. Ms Murphy also told the inquest that there was about a 10-minutewait in the emergency department from the time Alex came to the triage window to when he was looked at by her, as she was busy triaging another patient. Broken Hill teenager Alex Braes, who died of an infected toenail. Eighteen-year-old Alex Braes was pronounced dead. Download the ABC News app for all the latest. Mr Palmbach testified that the findings in the autopsy report about Paul's wounds - that the head wound was an exit wound - were "inconsistent" with the evidence which he testified shows . The inquest heard that at the hospital, only one doctor is on duty overnight and two nurses in the emergency department. 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. 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. ': 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. "Unfortunately it's a very serious omission that somebody who's been repeatedly in the emergency department hasn't been gone over with a fine-tooth comb," he said. But their boy suddenly deteriorated sharply. Alex Braes died on September 22, 2017, with a suspected flesh-eating bacteria known as necrotising fasciitis ravaging his system, after he was turned away three times from Broken Hill Hospitals emergency department. 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. 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. Annual training is also provided for coroners' officers. 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. 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. The inquest heard Mr Braes had an ingrown toenail in August 2017 that was successfully treated with antibiotics. Were working to restore it. Alex Braes, 18, had significant knee pain when he first presented to Broken Hill Hospital in the early hours of September 20, 2017. This resulted in Braes' parents being denied a formal investigation "for an inexcusable length of time," Ryan said. The inquest heard that during that time, Alex was in a wheelchair, John Braes had already reported Alex's knee problem, and they'd already seen a doctor. Alex Braes died at the Royal Prince Alfred Hospital in Sydney on September 22, 2017, after being transferred from Broken Hill Hospital. Enabling and empowering the medical community to come together. 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 . "Almost five years after Alex died this remains the case.". After his ultrasound, he expected a doctor to review his results but the emergency department was so busy, no-one could see him. Doctors suspected he had a ruptured tendon and recommended rest and ice. Ms Sullivan then asked whether the rule was dropped as a direct result of Alex passing away. Coroner's Report: With Willa Ford, Peter Barton, Michael Swan, Kyle Labine. As his pain began to worsen, he was taken to the hospital, where he was diagnosed with a fractured ankle. 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. Senior doctor gives evidence about Alex Braes' final hours on day two of inquest, Follow the action from the third Test between India and Australia in Delhi in our live blog, Former government services minister Stuart Robert is being questioned at theRobodebt inquiry, Keep up with the latest ASX and business news. 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 Follow our Australia news live blog for the latest updates, serious gaps in healthcare in rural and regional areas. 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