The Deputy State Coroner has criticised a regional hospital’s treatment of a boy who was repeatedly sent home before dying from sepsis.
Alex Braes, 18, had significant knee pain when he first presented to Broken Hill Hospital in the early hours of September 20, 2017.
It was not until his fourth and final presentation more than 30 hours later that vital observations were taken of him and a suspected toenail infection was identified.
He was taken to Royal Prince Alfred Hospital in Sydney but went into cardiac arrest and died soon after arriving during the early hours of September 22, 2017.
Deputy State Coroner Elizabeth Ryan delivered the inquest's findings in the Broken Hill courthouse on Monday.
She found that Mr Braes' cause of death was multi-organ failure due to sepsis from a group A streptococcus infection, and that he died as a result of natural causes.
Ms Ryan's report also noted that experts assembled for the inquest could not say what the original source of Alex's infection was.
In her comments before delivering the findings, Ms Ryan was critical of a business rule that was then in place at Broken Hill Hospital which effectively discouraged nurses from taking vital signs observations.
She said the inquest established there were shortcomings in the care provided to Mr Braes at the hospital.
"A significant one was the failure on September 20, 2017, to perform vital signs observations," Ms Ryan said.
She said it was likely that Mr Braes' temperature was measured that morning but not his pulse rate, rate of breathing or blood pressure.
She said as a hospital practice it was not compliant with NSW Health policy.
"After Alex's tragic death, Broken Hill Hospital retuned to the practice of taking a full set of vital signs measurements for all patients coming to the emergency department," she said.
Deputy Coroner Ryan's findings also noted that while there were deficiencies in the care given to Mr Braes, they did not cause or contribute to his death.
She noted that there was no realistic possibility that his specific infection could have been identified and successfully treated on September 20, 2017.
Transfer delays cause concern
Ms Ryan was also concerned that Mr Braes' retrieval and transfer out of Broken Hill Hospital was beset by numerous delays.
Mr Braes died a little more than an hour after being admitted.
"Furthermore, Alex was not transferred to the closest hospital suitable for his care, which was South Australia's Royal Adelaide Hospital," Ms Ryan said.
"This was a perverse outcome which demanded examination at the inquest."
She said evidence highlighted that Mr Braes was effectively refused admission to a South Australian tertiary hospital on September 21, 2017.
"There was no system whereby a New South Wales clinician could insist that a critically-ill, Broken Hill patient be accepted for treatment in South Australia," she said.
Ms Ryan said there had an been "extraordinary lack" of progress between NSW Health and SA Health establishing a formalised cross-border arrangement to transfer critically-ill patients from Broken Hill to Adelaide.
She recommended that, as matter of urgency, the health departments 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 also stressed within the delivery of the inquest's findings that doctors and nurses who attended to Mr Braes in Broken Hill were neither unprofessional or uncaring.
Far West Local Health District apologises
In a statement, the Far West Local Health District said it expressed its deepest sympathies to the family of Mr Braes and acknowledged the heartache caused by his death.
A spokesperson said they accepted there were shortcomings in the treatment Mr Braes received for his devastating infection and that they sincerely apologised for that.
"Many changes have already been implemented by Far West NSW Health District and NSW Ambulance."
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.
"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."
