Inquest into the death of Finlay Browne

16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related complications

Finlay Browne, a 16-year-old with Down syndrome, presented to Bathurst Base Hospital on 30 September 2016 with acute abdominal pain and vomiting. Despite clear clinical signs—including a lactate of 7.2 mmol/L (grossly abnormal), faeculent vomiting, and imaging showing caecal malrotation with volvulus—his condition was not recognised as a surgical emergency until late evening. Critical delays in senior physician oversight, delayed CT imaging interpretation, and failure to escalate to surgical consultation until 9pm resulted in his surgery commencing at 11:38pm. The 7+ hour delay meant extensive bowel had become ischaemic and non-viable. Although he underwent extensive surgery and retrieved to Sydney Children's Hospital, the degree of bowel necrosis was catastrophic and contributed to his death 71 days later. Systemic failures included: no qualified emergency physician leading care, placement in an unsupervised cubicle, failure to recognise unconscious bias affecting his care, inadequate escalation pathways, and late NETS involvement. Stronger clinical leadership, earlier senior review upon learning lactate result, and proper escalation would have provided a better chance of survival.