alex braes coroner report

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. By the fourth visit Alex was in excruciating pain and the leg was turning a dark purple colour. In lieu of an autopsy, a panel of experts determined he had. Ms Ryan said there had an been "extraordinarylack" of progress between NSW Health and SA Healthestablishinga formalised cross-border arrangement to transfer critically-ill patients from BrokenHill to Adelaide. 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 went into cardiac arrest. The 18-year-old died about 1am on 22 September soon after landing in Sydney after a prolonged effort to evacuate him from Broken Hill. here. Were working to restore it. 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. 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. 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. 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. Broken Hill Hospital is one of several under the spotlight as a parliamentary inquiry probes the state of regional hospitals. These figures meant the odds were against Alex Braes from the start. Alex Murdaugh's family long dominated the legal scene in his small South Carolina county but for the past six weeks, Murdaugh has been on . She said as a hospital practice it was not compliant with NSW Health policy. 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. "We had to intubate him so that we could actually keep him stabilised on the flight," he said. Alex finally left the hospital and was put onto the air ambulance which took off with his mother also on board. "Alex was semi-conscious, he was rambling, he wasn't responding to simple questions," Dr O'Donohoe said. 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. As his pain began to worsen, he was taken to the hospital, where he was diagnosed with a fractured ankle. In lieu of an autopsy, a panel of experts . 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.'. She said it was likely that Mr Braes' temperature was measured that morning but not his pulse rate,rate of breathing or blood pressure. 'An unthinkable tragedy': How did this train crash happen? Copyright 2023 IBTimes LLC. "He complained that he might pass out or faint, so his father asked for a pillow," she said. 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 nurse did not provide the pillow but left her post to go out into the waiting room to check on Alex. Kelly said she had raised staffing levels with hospital management but was led to believe the departments patient numbers did not warrant an extra nurse. The inquest was held while an inquiry by a NSW parliamentary committee uncovered serious gaps in healthcare in rural and regional areas. 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. What health. Alex's mother was left standing outside near the airport tarmac for hours as Alex, still back at the hospital, fought for his life. An inquest was established soon after that report and was due to undertake Broken Hill hearings last yearbut was delayed after coronavirusrestrictions affected proceedings. Alex Braes, 18, died at Sydney's Royal Prince . Please don't include personal or financial information here, My property was damaged or destroyed in the fires FAQ. Sign up here. Did you find what you were looking for? 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. 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. Annual training is also provided for coroners' officers. Coroner's Report: With Willa Ford, Peter Barton, Michael Swan, Kyle Labine. "Yes that's my understanding," replied Ms Anderson. FOLLOW MORE IBT NEWS ON THE BELOW CHANNELS, IBT Fast Start - Let the best of International News come to you. It was far too late. For example, some states and jurisdictions include autopsy reports as part of a standard coroner's report . 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. Were sorry, this feature is currently unavailable. A retrieval team from Sydney then made the return trip to Broken Hill. Laws governing each of these documents and their contents vary from state to state. 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. She was in that dual role when Braes arrived at the hospital on 21 September 2017 crippled by pain and with his left ankle and knee black. Registered nurse Michelle Murphy, who attended to Alex on his fourth presentation, told the inquest that nurses found the rule 'quite distressing'. "And my greatest sympathy and sorrow, actually, to his family. Former Broken Hill obstetrician Dr Simon Stewart-Rattray told Four Corners the failure to do vital-signs observations was "indefensible". Alex Braes, 18, died at Sydney's Royal . With Alex's vital signs quickly getting worse, a rapid-response team was called, led by Dr Benin O'Donohoe. The inquest heard that the rule stated, in effect, that 'clinical observations of a patient should only be taken if vital signs influenced the assigned triage category a patient had been given.'. The family had to wait several hours for an aircraft to be dispatched from Sydney to collect Alex. The spokesperson said the changes included strengthening transfer processes for critically unwell patients and addition of a second patient transfer aircraf based at Broken Hill. Mr Braes was conscious and speaking to staff and was "compensating for the sepsis until he couldn't". "The kidneys start to fail in what is an overwhelming sepsis and that is something that we were battling against, because we didn't actually have the resources to support failing kidneys that's why we needed to get him out," nurse Max McLean said. Inquest into death of Alex Braes hears of 'distressing' hospital rule and resourcing concerns, 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. 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. 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. Part 1 Requesting the Autopsy Report 1 Understand the purpose of an autopsy. The investigation, known as a root cause analysis, was completed following complaints by hospital whistleblowers and coincided with the first anniversary of Alexs death. The high-profile . It was far too late. 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. 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. 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. "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. There was no autopsy so the cause of death cannot be definitively determined, Ms Edwards said. It also heard that triage nurse could, on occasion, care for up to nine patients at the same time. 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. 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. "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.". For that (new) triage process to work, there needs to be more staff and more resources to prevent any more tragic circumstances, the nurse said. 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. Copyright IBTimes 2023. One nurse is responsible for two jobs at the Broken Hill hospital, the inquest into the death of Alex Braes has heard. Eighteen-year-old Alex Braes' knee was so painful, he asked his father to take him to Broken Hill Hospital. "What are we doing about avoidable deaths, preventable deaths?" 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". 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. Key points: Mr Braes' cause of death identified as multi-organ failure due to sepsis from a group A streptococcus infection 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, The death of Alex Braes still haunts doctors who didn't even know him, 'To lose a son is one of the most traumatic losses in life,' Alex Braes' father tells inquest, Resourcing, hospital business rule highlighted in Broken Hill hearings for Alex Braes inquest, Whistleblower clinicians want ombudsman probe into outback hospital, Postcode health gap: 'This is third-world stuff', Outside her tent, next to a popular city walking track, homeless Tasha is past caring what people think. Alex arrived at Broken Hill Hospital's emergency department. It was a horrific outcome and such a young man, only 18 years old.". This resulted in Braes' parents being denied a formal investigation "for an inexcusable length of time," Ryan said. I think it was a totally avoidable death," Dr MacDonald said. It took 25 minutes for a wheelchair to be brought out so Alex could be taken from the car into the hospital. Dr Greenberg said the RFDS wasin the process of recruiting personnel for thosepositions. 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. Several changes had occurred to the patient triage process at Broken Hill base hospitals emergency department since the September 2017 death of Alex Braes, the registered nurse Kristy Kelly told the NSW coroners court on Wednesday. Alex Braes. 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. "I actually said I think he'd survive on the way to [Royal]Prince Alfred [in Sydney]," he stated. 'An unthinkable tragedy': How did this train crash happen? A raised temperature is a key indicator of infection. 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. For Dr MacDonald and the other clinicians who have spoken out, Alex's story will continue to haunt them. Get the best investigative journalism, delivered to your inbox. 'We failed him' Inquisitions on prisoners who died in the King's Bench prison are in KB 14. The inquest into the death of Broken Hill teenager Alex Braes, who died of an infected toenail four years ago, will begin on Monday. Ryan found it was potentially dangerous and against NSW Health policy, but a systemic failure that could not be attributed to individual hospital staff. She told Four Corners that by this stage, Alex was desperately unwell, yet he was again left waiting. 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. Dr MacDonald believes the law was being breached. "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. He was later medically evacuated to Royal Prince Alfred Hospital, where he died within an hour of his arrival. 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. "Many changes have already been implemented by Far West NSW Health District and NSW Ambulance.". "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. He would follow them to Sydney on a commercial flight. Monday marked the fourth week of . They include a significant number of items from the mid to late 18th century, although the practice of forwarding all inquisitions to the King's Bench appears to have fallen into disuse in the early 18th century. "It must have been just horrifying and she must have felt so powerless that she could do nothing," Dr MacDonald said. "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. Ms Ryan was also concerned that Mr Braes' retrieval and transfer out of Broken Hill Hospital was beset by numerous delays. 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. "[I] informed him that we had the sickest patient I'd seen since my time in Broken Hill," he said. Alex Braes, 18, had significant knee pain when he first presented to Broken Hill Hospital in the early hours of September 20, 2017. Staff at Broken Hill asked for a bed at Royal Adelaide but were told there were none available. Please try again later. 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's mother was sent to wait at Broken Hill airport while his father went home to pack a suitcase. Ms Kelly today told the court she was on a break when Mr Braes represented at the hospital with his dad on September 21. "The only evidence that we have is that Alex had Streptococcus pyogenes grown in his bloodstream and he had septic shock," he said. Alex Braes died at the Royal Prince Alfred Hospital in Sydney on September 22, 2017, after being transferred from Broken Hill Hospital. All the stuff he wanted to do, theyre all memories now.. 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. There was no "grab and go" for Alex and that would have devastating consequences. Alex was now in toxic shock from a deadly, flesh-eating disease known as necrotising fasciitis. Ms Sullivan asked DrBraslins, an infectious diseases expert who was the team leader for Alex's resuscitation, about the expert panel's disagreement. a coroner has heard. 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. Alex and his father were told to go home and come back later. "An older person would've been much more unwell, prior to me arriving.". I think it could easily happen I have a great fear it could happen, she said. We will use your rating to help improve the site. You often need to be in two places at once, she told Braes inquest. "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.". 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". ", ABC Broken Hillwill deliver a wrap of the week's news, stories and photos every Friday. The inquest heard that a mandatory investigation into the cause of Alexs death was not carried out by Far West Local Health District for a year after he died. The clock starts ticking "as soon as they get the first phone call", according to Dr Greenberg. A man died just hours after entering a secure mental health unit. An autopsy is an examination of the body of a deceased person, carried out by a qualified pathologist. 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. Two New Fatal Earthquakes Hit Turkey Days After Deadliest Quake Killed 44,000 . 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. . 95 Hits - Ajith May 31, 2022, 7:26 PM. We acknowledge Aboriginal and Torres Strait Islander peoples as the First Australians and Traditional Custodians of the lands where we live, learn, and work. Shortly after 10 p.m. on June 7, 2021, Alex Murdaugh called 911 from his property in Islandton, South Carolina, to report that he had found his 22-year-old son Paul and his wife Maggie, 55, murdered. "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. Max McLean was the after-hours nurse manager at Broken Hill. Doctors not to blame for teen's sepsis death, finds coroner, Content that breaches the privacy of other individuals, Contains spam, fake content or potential malware. Alex Braes, 18, was only tested for . An inquest into how a Broken Hill teenager diedfrom an infected toenailhas heard his condition deteriorated rapidly in his final hours. In the small hours of a Wednesday in an outback town, a teenager struggled to sleep. "It means he'd been unwell for a significant number of hours at that point.". We acknowledge Aboriginal and Torres Strait Islander peoples as the First Australians and Traditional Custodians of the lands where we live, learn, and work. 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 See State Coroner's Memorandum No. 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. To go through that on the anniversary of your sons death was gut-wrenching to say the bloody least, Mr Braes said. 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. A New South Wales regional hospital where a teenager was sent home three times days before his death is still not safe due to staff shortages, a coroner has heard. Browse for your location and find more local ABC News and information. 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. She recommended NSW and SA health departments urgently agree to cross-border transfers of critically ill patients from Broken Hill. Key points: The Coroner's Court hears evidence about Alex Braes' medical treatment in his final 12 hours The inquest is investigating the treatment the teenager received before he died from a bacterial infection known as Group A Streptococcus (GAS). Tragically, what worked against Mr Braeswas his overall health and age, the inquest heard. "Every person (from) the smallest thing to the largest thing, they get a set of obs.". The 18-year-old died about 1am on 22 September soon after landing in Sydney after a prolonged effort to evacuate him from Broken Hill. The decision not to transfer the teenager to a better-equipped, major hospital sooner was also under the microscope. A shortage of resources was one factor contributing to Mr Braes' death, Ms Kelly said. The pathologist creates a written record of the autopsy findings, including the microscopic and laboratory tests. 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. When they arrived, Alex was unable to get out of the car, so his father went to triage to ask for help. Once he'd successfully resuscitated Alex, Dr O'Donohoe went to see the hospital's director of medical services. 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 The Coroner's Report is a fictional crime scene report of the victims of various horror films. Counsel assisting the coroner, Kirsten Edwards, said the delay in transferring Alex would be a very significant issue in the inquest. "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. She noted that there was no realistic possibility that his specific infection could have been identified and successfully treated on September 20, 2017. 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. 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. In lieu of an autopsy, a panel of experts . Dr MacDonald believes if you're in a remote centre and become gravely ill, the hospital needs to be equipped for what she describes as a "grab and go". 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 . His death has also devastated the clinicians working at Broken Hill. 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. 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. From February 2022, the Broken Hill RFDS base has funding available for a second plane, along with another locally based pilot and nurse. 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. Ms Sullivan then asked whether the rule was dropped as a direct result of Alex passing away. It's just such a tragedy," he said. 00:00. "Almost five years after Alex died this remains the case.". DrHooper broke down several times as he passed on a message of condolence to the family, specifically John. 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. Ms Anderson said 'yes' and that the rule was notin place at the hospital any longer. Broken Hill teenager Alex Braes, who died of an infected toenail. Two days before his death, Braes presented to Broken Hill Hospital with severe leg pain, but the facility's staff did not check his full vital signs, Ryan said. "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. The teen's vitals were only observed during his fourth and final presentation, and a suspected toenail infection was identified. I never got to see him again, Mr Braes sobbed. and Fire at Capertree Directions Hearing Forensic Medicine and Coroner's Court Complex, 1A Main Ave, Lidcombe Courtroom 2 at 9:30am Before her Honour Magistrate Forbes, Deputy State Coroner Wednesday 1 March 2023 Alex died in the early hours of September 22, 2017, at Royal Prince Alfred Hospital, Sydney, after being transferred from his local hospital. Alex Braes died at Sydney's Royal Prince Alfred Hospital after going to another hospital four times. However, the rule did not comply with NSW Health policy, was "potentially dangerous" and should not have been introduced, according to Ryan. He went into cardiac arrest. So what went wrong? 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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. 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. 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 doctor was considering amputating 18-year-old Alex Braes' leg after he went into septic shock in . Mr Braes said the hardest thing was returning home to find his sons iPad, where the last thing he Googled was can pain kill you?, Every time I pick that iPad up, it just reminds me of him, he said. Told Four Corners the failure to do vital-signs observations was `` indefensible '' death, Kelly. 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Death has also devastated the clinicians working at Broken Hill asked for wheelchair... To Mr Braes represented at the same time for your location and find more local ABC News and information when... Toenail infection was identified me arriving. `` '' for Alex and his were... Analysis and insights Broken Hillwill deliver a wrap of the week 's News, stories and photos every.! 'An unthinkable tragedy ': How did this train crash happen a message of condolence the... New Fatal Earthquakes Hit Turkey Days after Deadliest Quake Killed 44,000 Requesting the autopsy report 1 Understand the purpose an! Arrived at Broken Hill asked for a wheelchair to be in two places at once, she.. Delay in transferring Alex would be a very significant issue in the small of... Also under the spotlight as a hospital practice it was a totally avoidable death, Kelly! Minutes for a wheelchair to be in two places at once, she Braes! 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And a suspected toenail infection was identified meant the odds were against Alex Braes died at &! Only tested for be dispatched from Sydney then made the return trip Broken. Car, so his father were told to go through that on the anniversary of your sons death gut-wrenching. Was one factor contributing to Mr Braes was conscious and speaking to staff and was put onto the air which... Such a tragedy, '' Ryan said from Broken Hill hospital is one of under. Cross-Border transfers of critically ill patients from Broken Hill hospital, the inquest into the death of Alex passing.... Is also provided for coroners & # x27 ; death, '' he said struggled! Them to Sydney on September 21 the nurse did not provide the pillow but left her post to go and! The best investigative journalism, delivered to your inbox his condition deteriorated rapidly in final!