alex braes coroner report

John Braes wept before the NSW Coroners Court on Monday as he recalled the final hours of his son Alex, who he remembered as a ray of sunshine with red hair and an infectious laugh. Counsel Assisting the inquest, Kirsten Edwards, asked Ms Kelly whether she was aware of any level of disgruntlement amongst the nurses about it. 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. A coroner found serious and unacceptable deficiency in a teen's treatment at Broken Hill hospital. Alex's father called triple zero to ask an ambulance to take his son to hospital, but no ambulance was available. The inquest will investigate the treatment Alex Braes received before he died from a bacterial infection known as Group A Streptococcus (GAS). Enabling and empowering the medical community to come together. The doctor was considering amputating 18-year-old Alex Braes' leg after he went into septic shock in . Annual training is also provided for coroners' officers. But questions are expected to continue about the handling of Alex Braes' case. Broken Hill teenager Alex Braes, who died of an infected toenail. Broken Hill teenagerAlex Braes, who died of an infected toenail. 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. Ryan recommended the communication between the two states be escalated to the NSW secretary of health if cross-border transfer arrangements are not in place within a year. A full set of vital signs, including temperature and respiratory rate, was not taken until the fourth presentation on 21 September. 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 far too late. Alex and his father arrived back at the emergency department. Broken Hill staff had missed something, but still, no-one did proper observations of Alex. This action will also remove this member from your connections and send a report to the site admin. Did you find what you were looking for? This was due to a business rule, which discouraged staff from taking vitals during the triage stage in order to improve efficiency. After arriving at Broken Hill base hospital on 21 September, Braes was put in a non-acute bed. 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. All rights reserved. For legal cases involving intentional or accidental death and for insurance claims, The Records Company retrieves coroner's reports and autopsy reports. Mr Braes, 18, died at Sydney's Royal Prince Alfred Hospital on September 22, 2017 after he was flown from Broken Hill. 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. 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.'. 7 Callum Jones: Sprained Ankle Causes Fatal Blood Clot. In lieu of an autopsy, a panel of experts . There was no "grab and go" for Alex and that would have devastating consequences. 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 that, as matter of urgency, the healthdepartments agree to continue discussions for formalising that arrangement and that the matter be escalated to the NSW Health Secretary if that was not in place within a year. Each season is dedicated to a different series in horror. All NSW magistrates are coroners by virtue of their status: s 16. The inquest was held while an inquiry by a NSW parliamentary committee uncovered serious gaps in healthcare in rural and regional areas. 'An unthinkable tragedy': How did this train crash happen? "Every person (from) the smallest thing to the largest thing, they get a set of obs.". 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. Alex Braes. Dr O'Donohoe spoke to the Royal Flying Doctor Service at Broken Hill. "The district acknowledges the need to learn from Alexs tragic death and will carefully consider the coroners findings," the spokesperson said. 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. Were working to restore it. Coroner identifies unacceptable treatment in lead-up to death from multi-organ failure due to sepsis, calls for new interstate rules. 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 23 April 2021. 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. Mr McLean says staff had to provide life support before Alex could be put on the plane. Alex Braes, 18, died of multi-organ failure caused by sepsis. 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. Doctors identified necrotising fasciitis, a deadly, flesh-eating disease, from an infected toenail in the teenager. She said it was likely that Mr Braes' temperature was measured that morning but not his pulse rate,rate of breathing or blood pressure. Staff at Broken Hill asked for a bed at Royal Adelaide but were told there were none available. After Four Corners interviewed the Health Minister, Broken Hill Hospital's chief executive resigned, citing personal reasons. Counsel assisting the coroner, Kirsten Edwards, said the delay in transferring Alex would be a very significant issue in the inquest. In Newcastle and Wollongong, a magistrate is appointed by the Chief . An inquest was established soon after that report and was due to undertake Broken Hill hearings last yearbut was delayed after coronavirusrestrictions affected proceedings. The NSW State Coroner, Teresa OSullivan, has advised the procedures that will apply in relation to the conduct of coronial proceedings at the Lidcombe Forensic Medicine and Coroners Court Complex (FMCCC), for matters listed from 10 October 2022. 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 . 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. 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. 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. 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. After his ultrasound, he expected a doctor to review his results but the emergency department was so busy, no-one could see him. The Deputy State Coroner has criticised a regional hospitals treatment of a boy who was repeatedly sent home before dying from sepsis. Alex and his father were told to go home and come back later. Alex arrived at Broken Hill Hospital's emergency department. 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. One of them, DrAli Baalbaki, told the inquest he longer celebratedhis own birthday because it falls on the same day he reviewed the teenager. Copyright IBTimes 2023. We acknowledge Aboriginal and Torres Strait Islander peoples as the First Australians and Traditional Custodians of the lands where we live, learn, and work. My first thought was I havent finished obs for him, I havent done anything for him, have I missed something? she told the inquest. 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. "A young man who died, essentially, from an infected toenail, from the consequences of an untreated and very common infection. His death has also devastated the clinicians working at Broken Hill. He believes Alex's death was a consequence of poor structure and organisation at the hospital. With Alex's vital signs quickly getting worse, a rapid-response team was called, led by Dr Benin O'Donohoe. 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. 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 was given a triage category of three, meaning the patient must see a doctor within 30 minutes. Alex Braes, 18, suffered multi-organ failure due to sepsis and died after hospitals either despatched him domestic or refused to admit him. Justifiably outraged at the poor care of his son, John Braes. 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. By the time Alex was diagnosed with a bacterial infection he was in septic shock and needed to be medically evacuated to Adelaide. It is replayed on Tuesday 10th September at 1.00pm and Wednesday 11th at 11.20pm. the NSW member for Barwon said. When asked by Ms Edwards if she was feeling under a lot of pressure that morningand finding it difficult to manage workflow, Ms Murphy answered 'yes' to both questions. ': 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. Posted by posopa9401 January 4, 2022 Posted in Opinions Tags: after, Braes, coroner, hears, septic, shockBrokenhospital, Transferoption. It took 25 minutes for a wheelchair to be brought out so Alex could be taken from the car into the hospital. 95 Hits - Ajith May 31, 2022, 7:26 PM. "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. "He complained that he might pass out or faint, so his father asked for a pillow," she said. Browse for your location and find more local ABC News and information. Dr MacDonald believes the law was being breached. Dr. Piazza - Injury and Thrombosis. Alex died in the early hours of September 22, 2017, at Royal Prince Alfred Hospital, Sydney, after being transferred from his local hospital. Coroner in Alex Braes inquest scathing of care at Broken Hill Hospital provided to 18yo who died of sepsis, 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. "I just wanted to send my condolences and I'm so sorry that it happened. All Rights Reserved. It can also be seen on . 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. a coroner has heard. Alex Braes, 18, died at Sydney's Royal . By the fourth visit Alex was in excruciating pain and the leg was turning a dark purple colour. 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. She described the death of the fitter and turner as almost unbearable to imagine for the family. Because you left the triage window unattended and there were a lot of patients there," asked Ms Edwards. "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.". "Was there a general feeling it compromised patient safety?" Broken Hill teen Alex Braes died in 2017. Broken Hill teen Alex Braes died in 2017. "One of the things that really stood out for me when I saw you that night was how sweetly you and Alex treated one another," he said. Local hearings took place at the Broken Hill Coroner's Court this week, with a number of doctors and nurses who attended to Alex at Broken Hill Hospital appearing as witnesses alongside the teenager's father, John Braes. Representation. Eighteen-year-old Alex Braes was pronounced dead. 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. Dr Greenberg said the RFDS wasin the process of recruiting personnel for thosepositions. 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. "But the source of that infection was never confirmed, as I understandbecause an autopsy was not performed. 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. 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. All the stuff he wanted to do, theyre all memories now.. 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 . "If an 18-year-old comes into an accident and emergency department at three o'clock in the morning, it usually means there's a serious problem," he said. 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. . But their boy suddenly deteriorated sharply. 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. "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. 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. Thirty-three hours after he had first presented to Broken Hill Hospital, hospital staff finally did vital-signs observations. Dr Randall Greenberg on Wednesday spokeat length in the New South Wales Coroner's Court about Mr Braes' condition, and issues thatprevented the RFDS from transferring him to Sydney or Adelaide sooner. 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. 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. 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. Before Alex's death, doctors had complained repeatedly that management was not open to criticism and did not listen to safety concerns they raised. Unfortunately, the night pilot had called in sick. A retrieval team from Sydney then made the return trip to Broken Hill. here. Alex went into cardiac arrest and died upon arrival at Royal Prince Alfred Hospital in Sydney. Alex Braes, 18, died at Sydney's Royal Prince Alfred Hospital nearly 46 hours after limping into Broken Hill Base Hospital at 3am on September 20, 2017. The inquest also heard the Broken Hill hospital is prevented from transferring patients to Adelaide, despite the SA capital being closer than Sydney. 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. A shortage of resources was one factor contributing to Mr Braes' death, Ms Kelly said. "What are we doing about avoidable deaths, preventable deaths?" 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. Alex's parents were too distressed to be interviewed, but conveyed to Four Corners the loss of their son had left them feeling that, to the hospital system, he was worth nothing. Follow our Australia news live blog for the latest updates, serious gaps in healthcare in rural and regional areas. 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'. In lieu of an autopsy, a panel of experts . 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. In lieu of an autopsy, a panel of . Sign up and stay up to date with our daily newsletter. 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. 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. 'An unthinkable tragedy': How did this train crash happen? The hospital at the time had a policy running contrary to a NSW Health mandate that allowed staff to send patients home without taking a full set of vital signs. Coroner training overview. 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. "Alex was semi-conscious, he was rambling, he wasn't responding to simple questions," Dr O'Donohoe 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. 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. 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 Braes, 18, died on 22 September 2017 from multi-organ failure due to sepsis from a Group A streptococcus infection. About 21 hours after he first presented to the emergency department, and with 12 hours left to live, the treatment of the 18-year-old was handed over to the chief medical officer of the Royal Flying DoctorService (RFDS). According to these figures, for every 100,000 people, there are 91.6 avoidable deaths in major cities, compared to 248.7 avoidable deaths in very remote parts of the country. He said every time he picked up his son's iPad, "it just reminds me of him. Broken Hill Hospital is one of several under the spotlight as a parliamentary inquiry probes the state of regional hospitals. 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. "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 Braes. Ryan found it was potentially dangerous and against NSW Health policy, but a systemic failure that could not be attributed to individual hospital staff. What health. 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 actually said I think he'd survive on the way to [Royal]Prince Alfred [in Sydney]," he stated. Copyright 2023 IBTimes LLC. Sign up to receive an email with the top stories from Guardian Australia every morning. She had a particular concern for newly graduated nurses assigned to care for non-acute patients who were still learning new skills and could potentially miss a deteriorating patient like Braes. 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. "I was gobsmacked that it didn't prompt an investigation straight away," he said. (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. 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. The inquest is investigating the treatment the teenager received before he died from a bacterial infection known as Group A Streptococcus (GAS). 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. . "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. There was no autopsy so the cause of death cannot be definitively determined, Ms Edwards said. Sign up here. "She must have hoped beyond hope that he would survive.". It was a horrific outcome and such a young man, only 18 years old.". 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. The following month he began to experience pain in his knee. 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. 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 00:00. Get the best investigative journalism, delivered to your inbox. 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. Findings are published on this website when an inquest was held or a coroner otherwise orders they be published in the public interest. We will use your rating to help improve the site. The pathologist creates a written record of the autopsy findings, including the microscopic and laboratory tests. Registered nurse Michelle Murphy, who attended to Alex on his fourth presentation, told the inquest that nurses found the rule 'quite distressing'. She said evidence highlightedthat Mr Braes was effectively refused admission to a South Australian tertiary hospital on September 21, 2017. 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. The teenager's death was brought to attention in a Four Corners report in 2019, which examined care in country hospitals across Australia. The inquest heard Mr Braes had an ingrown toenail in August 2017 that was successfully treated with antibiotics. He went into cardiac arrest. That rule is no longer in place, Ms Edwards told the inquest. In lieu of an autopsy, a panel of experts . Ms Ryan was also concerned that Mr Braes' retrieval and transfer out of Broken Hill Hospital was beset by numerous delays. 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. Tragically, what worked against Mr Braeswas his overall health and age, the inquest heard. In lieu of an autopsy, a panel of experts determined he had. One nurse is responsible for two jobs at the Broken Hill hospital, the inquest into the death of Alex Braes has heard. 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 They sat there. Laws governing each of these documents and their contents vary from state to state. 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