Inquest into the death of Alex BRAES
Deceased
Alex Braes
Demographics
18y, male
Date of death
2017-09-22
Finding date
2022-05-30
Cause of death
Multi organ failure due to sepsis from a Group A streptococcus infection
AI-generated summary
Alex Braes, an 18-year-old from Broken Hill NSW, died of multi-organ failure due to Group A streptococcus sepsis. He presented to Broken Hill Base Hospital three times over 24 hours with knee pain that progressed to sepsis. Critical clinical lessons include: (1) the dangerous Business Rule that discouraged vital signs measurement at triage was a systemic failure—full vital signs should be routine for all ED patients; (2) vital signs were not taken on 20 September despite early clinical indicators (patient reported knee felt hot), missing an opportunity to prompt infection investigation; (3) however, expert consensus concluded that even if infection had been detected on 20 September, the aggressive GAS infection was irreversible by that time—there was no realistic possibility antibiotics could have saved him; (4) significant delays in his retrieval (over 12 hours) and refusal of Adelaide's Royal Adelaide Hospital to accept him as the closest appropriate facility exposed a critical systems failure in cross-border critical care arrangements between NSW and South Australia. The clinical lesson is that vital signs remain essential early screening tools, but also that no interstate mechanism existed to mandate acceptance of critically ill patients at the nearest suitable facility.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- Failure to perform full vital signs observations on 20 September 2017 due to Business Rule in ED
- Business Rule discouraged routine vital signs at triage, which was systemic failure not compliant with NSW Health policy
- Lack of clinical indicators at morning presentation on 20 September that would have pointed to infection
- Delays in retrieval and transfer process (over 12 hours from request to arrival at Sydney hospital)
- Refusal of Royal Adelaide Hospital to accept patient despite being closest suitable facility
- Lack of formal cross-border agreement between NSW and South Australia for critical care transfers
- Inadequate resourcing and staffing at Broken Hill Base Hospital
- Delay in intubation until shortly before transfer, when patient clinically deteriorated
Coroner's recommendations
- As a matter of urgency, the NSW Ministry of Health and the Department of Health and Wellbeing (SA) continue communication to agree and formalise cross-border arrangements for the transfer of critical care patients from Broken Hill to Adelaide tertiary care facilities, whether in the form of a 'default mechanism' or other formal agreement
- The matter be escalated to the Secretary, NSW Health, if the discussions referred to in Recommendation 1 do not lead to the establishment of formalised arrangements, as envisaged in Recommendation 1, within 12 months from the date of these findings
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