00:00. Ms Sullivan then asked whether the rule was dropped as a direct result of Alex passing away. We will use your rating to help improve the site. "He was cold, clammy, sweaty and he was significantly blue and mottled and this mottling colour is really a very ominous feature. His inquest has heard a full set of vital. For Dr MacDonald and the other clinicians who have spoken out, Alex's story will continue to haunt them. The highly experienced clinician also took time at the end of his testimony to address the Braes family directly. He suffered multi-organ failure due to sepsis from a group A streptococcus infection, one month after treatment for an infected ingrown toenail. WALTERBORO, S.C. . Alex's mother was left standing outside near the airport tarmac for hours as Alex, still back at the hospital, fought for his life. 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. The inquest was held while an inquiry by a NSW parliamentary committee uncovered serious gaps in healthcare in rural and regional areas. 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. 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 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. 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 about 46 hours after limping into Broken Hill Base Hospital at 3am on September 20, 2017. Coroners' inquisitions are also in KB 13 and KB 140. Unfortunately, the night pilot had called in sick. "I just wanted to send my condolences and I'm so sorry that it happened. Alex Murdaugh called 911 on the evening of June 7, 2021, and said he'd found his son and wife dead when he returned home from a one-hour visit with his mother, who has dementia. Dr MacDonald believes the law was being breached. 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. New South Wales Health Department figures show Broken Hill has the highest potentially avoidable death rate in New South Wales at 189 deaths per 100,000 people and most recent figures show it is rising. here. The practice was the result of a hospital "business rule" that discouraged staff from taking vitals during the triage stage in order to improve efficiency, the inquest heard. Alex finally left the hospital and was put onto the air ambulance which took off with his mother also on board. asked Ms Edwards. 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. For legal cases involving intentional or accidental death and for insurance claims, The Records Company retrieves coroner's reports and autopsy reports. The following month he began to experience pain in his knee. When a death is reported to the Coroner The coronial process explained for the family and friends of a deceased or missing person east Access to Coronial documents How to apply for documents used in an inquest or inquiry east Help and support Support for family and friends of a deceased or missing person east Before his Honour Magistrate Lee, Deputy State Coroner Wednesday 1 March 2023 Inquest into the Death of A.W. 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. "Certainly other hospitals will highlight a second presentation or third presentation, [to ask] 'have we missed something?'" "Was there a general feeling it compromised patient safety?" Representation. Broken Hill Base Hospital in NSW had a 'business rule' that discouraged the taking of routine vital signs at ED triage, reports hearing into Alex Braes' death in 2017. I never got to see him again, Mr Braes sobbed. "It means he'd been unwell for a significant number of hours at that point.". He said every time he picked up his son's iPad, "it just reminds me of him. "And my greatest sympathy and sorrow, actually, to his family. 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. 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. "Yes that's my understanding," replied Ms Anderson. 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. 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. 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. Mr Braes, 18, was misdiagnosed as having a torn knee tendon while he was battling a life-threatening bacterial infection. "A significant one was the failure on September 20, 2017, to perform vital signs observations," Ms Ryan said. He went into cardiac arrest. 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. ': 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. Mr McLean says by this stage Alex's third presentation alarm bells should have been ringing. It was far too late. Dr. Piazza - Injury and Thrombosis. He suffered multi-organ failure due to sepsis . It was a horrific outcome and such a young man, only 18 years old.". FOLLOW MORE IBT NEWS ON THE BELOW CHANNELS, IBT Fast Start - Let the best of International News come to you. See State Coroner's Memorandum No. Alex Braes died at the Royal Prince Alfred Hospital in Sydney on September 22, 2017, after being transferred from Broken Hill Hospital. A doctor who later saw Alex Braes said the 18-year-old was 'the sickest patient he'd ever seen at Broken Hill' hospital. . Alex Braes (Credit: ABC "Four Corners," family photograph) The death has traumatised Braes' family and hospital staff alike. Copyright IBTimes 2023. This was due to a business rule, which discouraged staff from taking vitals during the triage stage in order to improve efficiency. Counsel assisting the coroner, Kirsten Edwards, said the delay in transferring Alex would be a very significant issue in the inquest. A shortage of resources was one factor contributing to Braes death, Kelly said. Again, no-one checked Alex's vital signs. Witnesses told the inquest the rule had limited oversight from senior management and staff generally disapproved of it. 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. Coroner's Report: With Willa Ford, Peter Barton, Michael Swan, Kyle Labine. 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 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. Alex Braes, 18, was only tested for . 'We failed him' The Deputy State Coroner has criticised a regional hospitals treatment of a boy who was repeatedly sent home before dying from sepsis. 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. "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. 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. "This was a seriousand unacceptabledeficiency in his care and it was a missed opportunity to identify his underlying, evolving illness," she said. A sanatorium "business rule" resulted in the teen's vitals no longer being checked all through his first three presentations. Eighteen-year-old Alex Braes' knee was so painful, he asked his father to take him to Broken Hill Hospital. Updated: 7:51 AM EST Mar 1, 2023. Dr Greenberg told the inquest thathe first saw Mr Braesabout2:00pm on September 21, 2017, and from that moment on "I was the team leader". Each season is dedicated to a different series in horror. Alex Murdaugh's defence has rested its case after calling a total of 14 witnesses to try to convince jurors he is innocent of the murders of his wife Maggie and son Paul.. 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. Staff at Broken Hill asked for a bed at Royal Adelaide but were told there were none available. "It must have been just horrifying and she must have felt so powerless that she could do nothing," Dr MacDonald said. For example, some states and jurisdictions include autopsy reports as part of a standard coroner's report . Ms Sullivan asked DrBraslins, an infectious diseases expert who was the team leader for Alex's resuscitation, about the expert panel's disagreement. 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. "But the source of that infection was never confirmed, as I understandbecause an autopsy was not performed. After his ultrasound, he expected a doctor to review his results but the emergency department was so busy, no-one could see him. Ryan found it was potentially dangerous and against NSW Health policy, but a systemic failure that could not be attributed to individual hospital staff. Advertisement Ad 23 April 2021. Sign up here. Broken Hill Hospital is one of several under the spotlight as a parliamentary inquiry probes the state of regional hospitals. 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. 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 But their boy suddenly deteriorated sharply. Laws governing each of these documents and their contents vary from state to state. Editor's note: This article contains graphic descriptions from autopsy reports and witness testimony. 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. Can pain kill you?: Teens final words after he was turned away from NSW hospital. Ms Ryan's report also noted that experts assembled for the inquest could not say what the original source of Alex's infection was. Inquisitions on prisoners who died in the King's Bench prison are in KB 14. 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. "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.". As his pain began to worsen, he was taken to the hospital, where he was diagnosed with a fractured ankle. "Almost five years after Alex died this remains the case.". 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