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She said it was likely that Mr Braes' temperature was measured that morning but not his pulse rate,rate of breathing or blood pressure. 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. A medical student struggled to insert the cannula. "We had to intubate him so that we could actually keep him stabilised on the flight," he said. Jurors in the murder trial of disbarred South Carolina attorney Alex Murdaugh heard Monday about autopsy evidence on a day the court also publicly released body camera videos from law enforcement . It was far too late. 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. 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. There was no autopsy so the cause of death cannot be definitively determined, Ms Edwards said. Posted by posopa9401 January 4, 2022 Posted in Opinions Tags: after, Braes, coroner, hears, septic, shockBrokenhospital, Transferoption. But the 18-year-old mechanic died with "tragic suddenness",. 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. "Every person (from) the smallest thing to the largest thing, they get a set of obs.". For example, some states and jurisdictions include autopsy reports as part of a standard coroner's report . In addition to being told to return home on his first three visits to Broken Hill Hospital, Braes was also refused admission at a South Australian tertiary facility on Sept. 21, 2017, due to a policy preventing interstate transfers. The veteran clinician and patient-retrieval specialist, who has 36 years' experience, said he believed, inhindsight and now that he was "aware of the outcome", that there were a number of "ifs" including if Mr Braes had been takento Adelaide instead of Sydney. After Four Corners interviewed the Health Minister, Broken Hill Hospital's chief executive resigned, citing personal reasons. "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. Transfer 'only option' after teen Alex Braes went into septic shock in Broken Hill hospital, coroner hears. 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. Alex Braes. 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. He suffered multi-organ failure due to sepsis . The death of a healthy 18-year-old man who first attended a hospital with moderate knee pain is almost incomprehensible, she said. We acknowledge Aboriginal and Torres Strait Islander peoples as the First Australians and Traditional Custodians of the lands where we live, learn, and work. "Many changes have already been implemented by Far West NSW Health District and NSW Ambulance.". Unfortunately, the night pilot had called in sick. But the Flying Doctors were unable to transport Alex because the only available pilot had already reached their maximum flying hours a regulation governed by the Civil Aviation Safety Authority. Alex Braes, 18, died at the Royal Prince Alfred Hospital in . Mr McLean says staff had to provide life support before Alex could be put on the plane. Annual training is also provided for coroners' officers. 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. 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. Alex died in the early hours of September 22, 2017, at Royal Prince Alfred Hospital, Sydney, after being transferred from his local hospital. Outside her tent, next to a popular city walking track, homeless Tasha is past caring what people think. 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. During the flight Alex continued to decline and, as his mother watched, the paramedics struggled to keep him stable, having to phone doctors for advice. She described the death of the fitter and turner as almost unbearable to imagine for the family. 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. Download the ABC News app for all the latest. Sign up and stay up to date with our daily newsletter. 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. 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. We acknowledge Aboriginal and Torres Strait Islander peoples as the First Australians and Traditional Custodians of the lands where we live, learn, and work. Broken Hill teenager Alex Braes' parents remember him as a ray of sunshine, a funny and smart . Max McLean was the after-hours nurse manager at Broken Hill. (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. He believes Alex's death was a consequence of poor structure and organisation at the hospital. A raised temperature is a key indicator of infection. "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. 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. 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. If this is your first visit to the new AusDoc website, reset your password "Almost five years after Alex died this remains the case.". It will include an autopsy report, police report, the victim number of the series, personal information of the victim, and much, much more to make the Coroner's Report . After his ultrasound, he expected a doctor to review his results but the emergency department was so busy, no-one could see him. As his pain began to worsen, he was taken to the hospital, where he was diagnosed with a fractured ankle. 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. 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 . Liverpool welcomes UEFA report on Champions League final chaos in Paris. The inquest heard that at the hospital, only one doctor is on duty overnight and two nurses in the emergency department. "I just wanted to send my condolences and I'm so sorry that it happened. This was due to a business rule, which discouraged staff from taking vitals during the triage stage in order to improve efficiency. The investigation, known as a root cause analysis, was completed following complaints by hospital whistleblowers and coincided with the first anniversary of Alexs death. 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. 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. Alex and his father arrived back at the hospital. Broken Hill teenager Alex Braes's 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. Coroner identifies unacceptable treatment in lead-up to death from multi-organ failure due to sepsis, calls for new interstate rules. 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 It was far too late. 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. He said every time he picked up his son's iPad, "it just reminds me of him. "He was our first child, our ray of sunshine," he said. Key points: The Coroner's Court hears evidence about Alex Braes' medical treatment in his final 12 hours You often need to be in two places at once, she told Braes inquest. She noted that there was no realistic possibility that his specific infection could have been identified and successfully treated on September 20, 2017. Enabling and empowering the medical community to come together. Get the best investigative journalism, delivered to your inbox. Alex was now in toxic shock from a deadly, flesh-eating disease known as necrotising fasciitis. 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. The inquest is investigating the treatment the teenager received before he died from a bacterial infection known as Group A Streptococcus (GAS). In lieu of an autopsy, a panel of experts . The 18-year-old TAFE student's death was featured in a Four Corners report, which revealed he presented to Broken Hill Hospital's emergency department four times before vital signs observations were administered. Authorities said . The high-profile . Mr Braes, 18, died at Sydney's Royal Prince Alfred Hospital on September 22, 2017 after he was flown from Broken Hill. The doctor was considering amputating 18-year-old Alex Braes' leg after he went into septic shock in . 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 finally left the hospital and was put onto the air ambulance which took off with his mother also on board. It is replayed on Tuesday 10th September at 1.00pm and Wednesday 11th at 11.20pm. We will use your rating to help improve the site. "I didn't know his family, I didn't know Alex Braes. 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