'An unthinkable tragedy': How did this train crash happen? 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, 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. Ironically, though, the sudden death of Dudley's wife in September 1560 removed any hope that the queen might have . 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. My first thought was I havent finished obs for him, I havent done anything for him, have I missed something? she told the inquest. The day's hearing also heard from DrDevinda Arangala, who reviewed Alex during the early hours of September 20, 2017, when the teenager first presented to the hospital with a sore knee. We acknowledge Aboriginal and Torres Strait Islander peoples as the First Australians and Traditional Custodians of the lands where we live, learn, and work. Deputy State Coroner Elizabeth Ryan delivered the inquest's findings in the Broken Hill courthouse on Monday. We acknowledge Aboriginal and Torres Strait Islander peoples as the First Australians and Traditional Custodians of the lands where we live, learn, and work. 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. 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 second day of hearings heard from DrDavid Hooper, who reviewed Alex during his third presentation to the local hospital on September 20, 2017. Alex finally left the hospital and was put onto the air ambulance which took off with his mother also on board. Dr MacDonald believes the law was being breached. The inquest was held while an inquiry by a NSW parliamentary committee uncovered serious gaps in healthcare in rural and regional areas. However, the rule did not comply with NSW Health policy, was "potentially dangerous" and should not have been introduced, according to Ryan. The high-profile . 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. SA Health, for its part, has commenced discussions with its NSW counterpart on how to continue to best provide services on an ongoing basis. 7 Callum Jones: Sprained Ankle Causes Fatal Blood Clot. I think it could easily happen I have a great fear it could happen, she said. By the fourth visit Alex was in excruciating pain and the leg was turning a dark purple colour. Doctors suspected he had a ruptured tendon and recommended rest and ice. The family had to wait several hours for an aircraft to be dispatched from Sydney to collect Alex. 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. He revealed all the medical staff "misjudged" Mr Braes, who was "compensating very well" because he was "a young, fit fellow". 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 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. All Rights Reserved. Ms Kelly today told the court she was on a break when Mr Braes represented at the hospital with his dad on September 21. She said evidence highlightedthat Mr Braes was effectively refused admission to a South Australian tertiary hospital on September 21, 2017. Alex and his father arrived back at the emergency department. "But the source of that infection was never confirmed, as I understandbecause an autopsy was not performed. 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. It was far too late. "It means he'd been unwell for a significant number of hours at that point.". 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. Counsel Assisting the inquest, Kirsten Edwards, asked Ms Kelly whether she was aware of any level of disgruntlement amongst the nurses about 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. "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. The highly experienced clinician also took time at the end of his testimony to address the Braes family directly. "A significant one was the failure on September 20, 2017, to perform vital signs observations," Ms Ryan said. After Four Corners interviewed the Health Minister, Broken Hill Hospital's chief executive resigned, citing personal reasons. All rights reserved. We will use your rating to help improve the site. In lieu of an autopsy, a panel of experts determined he had. Broken Hill staff had missed something, but still, no-one did proper observations of Alex. 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. That rule is no longer in place, Ms Edwards told the inquest. 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. . This action will also remove this member from your connections and send a report to the site admin. 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She said the inquest established therewereshortcomings in thecare provided to MrBraes at the hospital. Enabling and empowering the medical community to come together. But the 18-year-old mechanic died with "tragic suddenness",. Alex Braes, 18, died at the Royal Prince Alfred Hospital in . One of them, DrAli Baalbaki, told the inquest he longer celebratedhis own birthday because it falls on the same day he reviewed the teenager. Bol says B sample clears him of doping positive. 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 . "No-one deserves to lose a child, no one deserves to go through this, and I can't begin to imagine what this is like for you.". 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AEST = Australian Eastern Standard Time which is 10 hours ahead of GMT (Greenwich Mean Time), abc.net.au/news/senior-treating-doctor-reflects-on-day-two-of-alex-braes-inquest/100703130, 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. 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 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. "This was a seriousand unacceptabledeficiency in his care and it was a missed opportunity to identify his underlying, evolving illness," she said. Get the best investigative journalism, delivered to your inbox. 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. 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. Dr O'Donohoe later quit work at Broken Hill Hospital over what he saw as mismanagement, leading to patient safety issues. 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. here. 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. 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. "I feel heartbroken that I still have my children and that you've lost your boy.". Before his Honour Magistrate Lee, Deputy State Coroner Wednesday 1 March 2023 Inquest into the Death of A.W. The decision not to transfer the teenager to a better-equipped, major hospital sooner was also under the microscope. Ms Anderson was then asked when the rule was disbanded. 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. 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. 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. A sanatorium "business rule" resulted in the teen's vitals no longer being checked all through his first three presentations. But one nurse was still responsible for both triaging patients in the waiting room and overseeing the departments nursing team. The NSW deputy state coroner criticized Broken Hill Hospital's shortcomings in its treatment of Braes, including its failure to perform vital signs observations at the emergency department. 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. I have found the failure to perform vital signs observations was a serious deficiency in the care provided to Alex, Ryan said in her findings. Sign up to receive an email with the top stories from Guardian Australia every morning. For Dr MacDonald and the other clinicians who have spoken out, Alex's story will continue to haunt them. 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. "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.". Alex Braes, 18, had significant knee pain when he first presented to Broken Hill Hospital in the early hours of September 20, 2017. Key points: Mr Braes' cause of death identified as multi-organ failure due to sepsis from a group A streptococcus infection Coroner training overview. 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. "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. I think it was a totally avoidable death," Dr MacDonald said. "I'm so sorry that this happened to you," said DrArangala to the Braes family in an emotional, sombre tone. Please allow a few minutes for this process to complete. Before Alex's death, doctors had complained repeatedly that management was not open to criticism and did not listen to safety concerns they raised. The teen's vitals were only observed during his fourth and final presentation, and a suspected toenail infection was identified. She was in that dual role when Mr Braes arrived at the hospital on September 21, 2017 - crippled by pain and . 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". Sign up here. He called his father home from work. 'We failed him' Deputy Coroner Ryan's findings also noted that whilethere were deficiencies in the care given to Mr Braes, theydid not cause or contribute to his death. Alex Braes, 18, died on 22 September 2017 from multi-organ failure due to sepsis from a Group A streptococcus infection. Sign up and stay up to date with our daily newsletter. Alex was told to go home and come back later that morning for an ultrasound. "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.". In lieu of an autopsy, a panel of experts . "The only evidence that we have is that Alex had Streptococcus pyogenes grown in his bloodstream and he had septic shock," he said. Broken Hill teen Alex Braes died in 2017. "There was no system whereby a New South Wales clinician could insistthat acritically-ill, Broken Hill patient be accepted for treatment in South Australia," she said. She has recommended that the states' respective health departments continue discussions for formalizing that arrangement and for the matter to be escalated to the NSW Health Secretary if it fails to be in place within a year. Eighteen-year-old Alex Braes' knee was so painful, he asked his father to take him to Broken Hill Hospital. There was no "grab and go" for Alex and that would have devastating consequences. Browse for your location and find more local ABC News and information. Alex Braes presented to Broken Hill Hospital four times over a more than 30 hour period in September 2017 (Noah Schultz-Byard) The second day of hearings heard from Dr David Hooper, who reviewed Alex during his third presentation to the local hospital on September 20, 2017. "I just wanted to send my condolences and I'm so sorry that it happened. Alex's mother was sent to wait at Broken Hill airport while his father went home to pack a suitcase. Alex's mother was left standing outside near the airport tarmac for hours as Alex, still back at the hospital, fought for his life. "Yes that's my understanding," replied Ms Anderson. Ms Ryan was also concerned that Mr Braes' retrieval and transfer out of Broken Hill Hospital was beset by numerous delays. Alex Murdaugh, a once prominent Hampton-based attorney from a well-known politically . Witnesses told the inquest the rule had limited oversight from senior management and staff generally disapproved of it. "Twelvehours passed before hisemergency flight landed at Sydney's Royal Price Alfred Hospital," Ms Ryan said. They sat there. 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. Advertisement Ad Once he'd successfully resuscitated Alex, Dr O'Donohoe went to see the hospital's director of medical services. "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. 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. Experts assembled for the inquest said they had notcompletely agreed on the cause of Alex's death. She recommended NSW and SA health departments urgently agree to cross-border transfers of critically ill patients from Broken Hill. 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 doctor described him as the sickest patient he had ever seen at Broken Hill. abc.net.au/news/alex-braes-inquest-findings-health-systems-criticised/101109422 The Deputy State Coroner has criticised a regional hospital's treatment of a boy who was repeatedly sent home before dying from sepsis. 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 "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. "Many changes have already been implemented by Far West NSW Health District and NSW Ambulance.". "Alex was semi-conscious, he was rambling, he wasn't responding to simple questions," Dr O'Donohoe said. 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. There was no bed available in Adelaide and a pilot could not take him to Sydney without exceeding his maximum allowable working hours. 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. "Every person (from) the smallest thing to the largest thing, they get a set of obs.". Representation. Please note: Inquisitions on prisoners who died in the King's Bench prison are in KB 14. 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. 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. ", ABC Broken Hillwill deliver a wrap of the week's news, stories and photos every Friday. Mr Braes died a little more than an hour after being admitted. Ms Anderson said 'yes' and that the rule was notin place at the hospital any longer. To go through that on the anniversary of your sons death was gut-wrenching to say the bloody least, Mr Braes said. Each season is dedicated to a different series in horror. Broken Hill teenager Alex Braes, who died of an infected toenail. It took 25 minutes for a wheelchair to be brought out so Alex could be taken from the car into the hospital. 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. Download the ABC News app for all the latest. The inquest into the death of Broken Hill teenager Alex Braes, who died of an infected toenail four years ago, will begin on Monday.