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. Editor's note: This article contains graphic descriptions from autopsy reports and witness testimony. The following month he began to experience pain in his knee. 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. A man died just hours after entering a secure mental health unit. Alex Braes, of Broken Hill, died in the early hours of Sept. 22, 2017, upon arriving at Royal Prince Alfred Hospital in Sydney, 7News.com.au reported. By the time Alex was diagnosed with a bacterial infection he was in septic shock and needed to be medically evacuated to Adelaide. Advertisement Ad "A young man who died, essentially, from an infected toenail, from the consequences of an untreated and very common infection. Senior doctor gives evidence about Alex Braes' final hours on day two of inquest, 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. See State Coroner's Memorandum No. Again, no-one checked Alex's vital signs. New South Wales Health Department figures show Broken Hill has the highest potentially avoidable death rate in New South Wales at 189 deaths per 100,000 people and most recent figures show it is rising. Mr Braes, 18, was misdiagnosed as having a torn knee tendon while he was battling a life-threatening bacterial infection. He believes Alex's death was a consequence of poor structure and organisation at the hospital. She noticed he was sweaty and unwell and moved him into a bed in the emergency department. In lieu of an autopsy, a panel of experts determined he had an unusual presentation of a fast-acting, highly lethal infection, the NSW Coroners Court has been told. Sign up here. 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. Elizabeth Keft returned, with IV bag in hand, to see doctors and nurses working on Braes in a resuscitation bay. Tragically, what worked against Mr Braeswas his overall health and age, the inquest heard. In lieu of an autopsy, a panel of experts . Watch Louise Milligan's investigation on iview. 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. 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. Mr Braes said no ambulance came when he called triple zero and he had to drive his son to hospital, where there were further delays while staff tried to locate a wheelchair. AEST = Australian Eastern Standard Time which is 10 hours ahead of GMT (Greenwich Mean Time), abc.net.au/news/alex-braes-inquest-findings-health-systems-criticised/101109422, Get breaking news alerts directly to your phone with our app, Help keep family & friends informed by sharing this article, 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. 95 Hits - Ajith May 31, 2022, 7:26 PM. Alex Braes died at Sydney's Royal Prince Alfred Hospital after going to another hospital four times. 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Dr Hooper, who resigned from his position as a senior visiting medical officer at Broken Hill Hospital two months ago, told the inquest yesterday that Mr Braes' death was a "profound event" in his life. The investigation, known as a root cause analysis, was completed following complaints by hospital whistleblowers and coincided with the first anniversary of Alexs death. 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, 'Can pain kill you? "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. Alex's mother was sent to wait at Broken Hill airport while his father went home to pack a suitcase. FOLLOW MORE IBT NEWS ON THE BELOW CHANNELS, IBT Fast Start - Let the best of International News come to you. "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. Posted by posopa9401 January 4, 2022 Posted in Opinions Tags: after, Braes, coroner, hears, septic, shockBrokenhospital, Transferoption. He revealed all the medical staff "misjudged" Mr Braes, who was "compensating very well" because he was "a young, fit fellow". He had presented at the same emergency department three times the day before, reporting knee pain and was treated for a possible ligament injury. The majority of Coroner's findings following an inquest are available to the public. From February 2022, the Broken Hill RFDS base has funding available for a second plane, along with another locally based pilot and nurse. 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. A NSW coronial inquest is examining the care Mr Braes received at Broken Hill Hospital, why his vital signs weren't taken until his third visit to the emergency department in two days and why it took hours for the 18-year-old to be medically evacuated out of the country town. In the Sydney metropolitan area, coronial matters are always handled by the State Coroner and Deputy State Coroners (senior coroners) situated at the Lidcombe Forensic Medicine and Coroners Court Complex. A coroner has blasted a NSW hospital for attempting to avoid an investigation into a teenager's death from sepsis after he was sent home from its emergency department, finding efforts to deny the significance of the tragedy inexcusable and deeply distressing to his family. 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. By the following morning, Alex's pain was so excruciating, he couldn't walk. 23 April 2021. Doctors at the hospital initially suspected that Braes' pain was caused by a ruptured tendon even though the teen's father mentioned he did not play sports, a report by the Sydney Morning Herald said. Ms Edwards said it is a NSW Health policy that hospitals check vital signs before discharging a patient from emergency. 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. "Twelvehours passed before hisemergency flight landed at Sydney's Royal Price Alfred Hospital," 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. A shortage of resources was one factor contributing to Braes death, Kelly said. 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. 7 Callum Jones: Sprained Ankle Causes Fatal Blood Clot. 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. Before his Honour Magistrate Lee, Deputy State Coroner Wednesday 1 March 2023 Inquest into the Death of A.W. "Certainly other hospitals will highlight a second presentation or third presentation, [to ask] 'have we missed something?'" 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. "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. 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. . Witnesses told the inquest the rule had limited oversight from senior management and staff generally disapproved of it. Doctors suspected he had a ruptured tendon and recommended rest and ice. "What I do know is it was not a satisfactory outcome and that's why when I heard about it from the doctors, I had the ministry go back out there, go through it, and determine why this had been downgraded," he said. The inquest is investigating the treatment the teenager received before he died from a bacterial infection known as Group A Streptococcus (GAS). When asked by Ms Edwards if she was feeling under a lot of pressure that morningand finding it difficult to manage workflow, Ms Murphy answered 'yes' to both questions. 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. (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. 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 . Please confirm you want to block this member. 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.. Dr Randall Greenberg on Wednesday spokeat length in the New South Wales Coroner's Court about Mr Braes' condition, and issues thatprevented the RFDS from transferring him to Sydney or Adelaide sooner. It is replayed on Tuesday 10th September at 1.00pm and Wednesday 11th at 11.20pm. Broken Hill teen Alex Braes died in 2017. Alex Braes, 18, had significant knee pain when he first presented to Broken Hill Hospital in the early hours of September 20, 2017. 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. "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. 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. 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 . 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. Doctors, who failed to check the vital signs of a teen who died from sepsis, are not responsible for the tragedy, according to a coroner who says they were prevented from doing so under a hospital business rule. 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. His death has also devastated the clinicians working at Broken Hill. asked Ms Edwards. In lieu of an autopsy, a panel of experts determined he had an unusual presentation of a fast-acting, highly lethal infection called invasive group A streptococcal. The "first and only option" available to a specialist doctor treating a gravely ill teenager in a country hospital was to fly him elsewhere, a coroner has been told. "[I] informed him that we had the sickest patient I'd seen since my time in Broken Hill," he said. Can pain kill you?: Teens final words after he was turned away from NSW hospital. A teenager who had been turned away three times from Broken Hill Hospitals emergency department Googled can pain kill you? on his tablet device before he died from septic shock. The pathologist creates a written record of the autopsy findings, including the microscopic and laboratory tests. "He was our first child, our ray of sunshine," he said. Part 1 Requesting the Autopsy Report 1 Understand the purpose of an autopsy. Because you left the triage window unattended and there were a lot of patients there," asked Ms Edwards. "But the source of that infection was never confirmed, as I understandbecause an autopsy was not performed. Max McLean was the after-hours nurse manager at Broken Hill. Coroner's Report: With Willa Ford, Peter Barton, Michael Swan, Kyle Labine. 'An unthinkable tragedy': How did this train crash happen? She was in that dual role when Mr Braes arrived at the hospital on September 21, 2017 - crippled by pain and . Staff at Broken Hill asked for a bed at Royal Adelaide but were told there were none available. She said the inquest established therewereshortcomings in thecare provided to MrBraes at the hospital. Alex Braes (Credit: ABC "Four Corners," family photograph) The death has traumatised Braes' family and hospital staff alike. Outside her tent, next to a popular city walking track, homeless Tasha is past caring what people think. Alex Braes is believed to have died from a type of flesh eating bacteria, known as necrotising fasciitis, after he was turned away three times from Broken Hill Hospital's emergency department in . Alex was told to go home and come back later that morning for an ultrasound. 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 . The inquest also heard the Broken Hill hospital is prevented from transferring patients to Adelaide, despite the SA capital being closer than Sydney. In the small hours of a Wednesday in an outback town, a teenager struggled to sleep. "And I think that the clinicians who would have been with him when he was so sick in emergency will not forget him.". She had a particular concern for newly graduated nurses assigned to care for non-acute patients who were still learning new skills and could potentially miss a deteriorating patient like Braes. By the fourth visit Alex was in excruciating pain and the leg was turning a dark purple colour. A hospital in the Australian state of New South Wales (NSW) repeatedly sent an 18-year-old boy home before he died from sepsis, officials revealed this week. I don't even know what he looks like. Alex went into cardiac arrest and died upon arrival at Royal Prince Alfred Hospital in Sydney. Sign up and stay up to date with our daily newsletter. Alex Braes. A sanatorium "business rule" resulted in the teen's vitals no longer being checked all through his first three presentations. As for the delays in Braes' transfer, the coroner pointed out that the teen was not taken to South Australia's (SA) Royal Adelaide Hospital despite the facility being the closest hospital suitable for his care. Enabling and empowering the medical community to come together. "She must have hoped beyond hope that he would survive.". If this is your first visit to the new AusDoc website, reset your password "Because it's not good enough in 2019 to have people in the far west of New South Wales having worse health outcomes than people in the city.". Coroner training overview. 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. "Was there a general feeling it compromised patient safety?" They sat there. After arriving at Broken Hill base hospital on 21 September, Braes was put in a non-acute bed. As for the delays in Braes' transfer, the coroner pointed out that the teen was not taken to South Australia's (SA) Royal Adelaide Hospital despite the facility being the closest hospital suitable for his care. 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. Alex Braes, 18, died at the Royal Prince Alfred Hospital in . The inquest heard Mr Braes had an ingrown toenail in August 2017 that was successfully treated with antibiotics. Copyright IBTimes 2023. Authorities said . 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. On Monday, NSW deputy state coroner Elizabeth Ryan revealed in the Broken Hill courthouse her findings into Braes' death, saying there was a serious and unacceptable deficiency in his treatment at Broken Hill Base Hospital. Due to restrictions imposed by the Civil Aviation Safety Authority, pilots can only fly 11 hours a day, with a possible extension of one hour. An inquest was established soon after that report and was due to undertake Broken Hill hearings last yearbut was delayed after coronavirusrestrictions affected proceedings. 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. That rule is no longer in place, Ms Edwards told the inquest. Representation. One nurse is responsible for two jobs at the Broken Hill hospital, the inquest into the death of Alex Braes has heard. Mr McLean says he spoke up and tried to get something done but he was ignored by hospital management. 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. 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. There was no "grab and go" for Alex and that would have devastating consequences. Alex Braes. 00:00. A traumatised doctor has broken down in tears at an inquest, reflecting on how a relatively well teenager was joking with his father the night before his sudden death. 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. In lieu of an autopsy, a panel of experts . a coroner has heard. "Alex was semi-conscious, he was rambling, he wasn't responding to simple questions," Dr O'Donohoe said. These figures meant the odds were against Alex Braes from the start. Were sorry, this feature is currently unavailable. The Coroner's Report is a fictional crime scene report of the victims of various horror films. Coroner's report into the death of Amy Robsart, August 1561 (KB 9/1073/f.80) For all that she liked to keep foreign suitors in play, Elizabeth was already deeply in love with her Master of Horse, Robert Dudley. Did you find what you were looking for? here. Alex Braes, 18, died of multi-organ failure caused by sepsis. The 18-year-old died about 1am on September 22 soon after landing in Sydney after a prolonged effort to evacuate him from Broken Hill. A traumatised doctor has broken down in tears at an inquest, reflecting on how a relatively well teenager was joking with his father the night before his sudden death. NSW coroner Elizabeth Ryan also outlined major delays in transferring Alex Braes from Broken Hill to the Sydney hospital where he died. Please don't include personal or financial information here, My property was damaged or destroyed in the fires FAQ. Ms Murphy also told the inquest that there was about a 10-minutewait in the emergency department from the time Alex came to the triage window to when he was looked at by her, as she was busy triaging another patient. Mr Braes, 18, died at Sydney's Royal Prince Alfred Hospital on September 22, 2017 after he was flown from Broken Hill. 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. The day's hearing also heard from DrDevinda Arangala, who reviewed Alex during the early hours of September 20, 2017, when the teenager first presented to the hospital with a sore knee. "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.". Instead, medical staff in the emergency department made the assumption Alex had a sporting injury. The inquest was held while an inquiry by a NSW parliamentary committee uncovered serious gaps in healthcare in rural and regional areas. Friday, 2.00am Eighteen-year-old Alex Braes was pronounced dead. He went into cardiac arrest. 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. 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 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. 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. Dr Greenberg explained to the inquestthat the situation was the same in Dubbo, where the pilot's hours had also expired. 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. Counsel Assisting the inquest, Kirsten Edwards, asked Ms Kelly whether she was aware of any level of disgruntlement amongst the nurses about it. The clock starts ticking "as soon as they get the first phone call", according to Dr Greenberg. Key points: Mr Braes' cause of death identified as multi-organ failure due to sepsis from a group A streptococcus infection The teenager's death was brought to attention in a Four Corners report in 2019, which examined care in country hospitals across Australia. We will use your rating to help improve the site. "The district acknowledges the need to learn from Alexs tragic death and will carefully consider the coroners findings," the spokesperson 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. Inquisitions on prisoners who died in the King's Bench prison are in KB 14. 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. "To the extentthere were deficiencies in your clinical practice, do you think one cause was you feeling under time pressure? The highly experienced clinician also took time at the end of his testimony to address the Braes family directly. My first thought was I havent finished obs for him, I havent done anything for him, have I missed something? she told the inquest. More from Latest News Danish ex-minister charged with revealing state secrets In conjunction with the Chief Coroner, the Judicial College delivers a varied training programme for all coroners involving induction, continuation and one-day training on specific topics. The hospital at the time had a policy running contrary to a NSW Health mandate that allowed staff to send patients home without taking a full set of vital signs. "I was gobsmacked that it didn't prompt an investigation straight away," he said. Our Morning Edition newsletter is a curated guide to the most important and interesting stories, analysis and insights. 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. Australian Institute of Health and Welfare figures released in July show the further Australians live from capital cities, the higher the rate of potentially avoidable deaths. a coroner has heard. While Broken Hill Hospital's deficiencies did not cause or contribute to Braes' death, the hospital's administration and the Far West Local Health District downgraded the severity classification of the incident. "Almost five years after Alex died this remains the case.". A medical student struggled to insert the cannula. 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. Alex's father managed to bundle his six-foot-three son into the family's car and drive for a fourth time to the emergency department. Eighteen-year-old Alex Braes' knee was so painful, he asked his father to take him to Broken Hill Hospital. "I remember thinking that I wished I would have the same relationship with my children when they grew up. Alex finally left the hospital and was put onto the air ambulance which took off with his mother also on board. Alex Braes died at the Royal Prince Alfred Hospital in Sydney on September 22, 2017, after being transferred from Broken Hill Hospital. The teen's vitals were only observed during his fourth and final presentation, and a suspected toenail infection was identified. The inquest will continue on August 31 with Sydney-based hearings. His inquest has heard a full set of vital. 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. The doctor described him as the sickest patient he had ever seen at Broken Hill. He would follow them to Sydney on a commercial flight. He went into cardiac arrest. SA Health, for its part, has commenced discussions with its NSW counterpart on how to continue to best provide services on an ongoing basis. Alex Braes died at the Broken Hill hospital, the inquest will continue on August 31 with hearings! A second presentation or third presentation, [ to ask ] 'have missed... Died of multi-organ failure caused alex braes coroner report sepsis Alfred hospital in was identified curated to! Braes was pronounced dead lot of patients there, '' he said also on board autopsy was not performed caring. More IBT news on the BELOW CHANNELS, IBT Fast Start - Let the best International... 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In transferring Alex Braes from the Start was identified ask for help for him, I havent done for... A bed in the emergency department patient from emergency it is replayed on 10th. And come back later that morning for an ultrasound they get the first phone ''. Was our first child, our ray of sunshine, '' Ms Ryan said says! Was no `` grab and go '' for Alex and that would have devastating.. News live blog for the latest updates, serious gaps in healthcare in rural regional... We missed something? ' time pressure was put in a resuscitation bay a bed! From transferring patients to Adelaide, despite the SA capital being closer than Sydney I something! Nurse manager at Broken Hill hospital alex braes coroner report hospitals check vital signs before discharging a patient from emergency to be evacuated... Time pressure during his fourth and final presentation, [ to ask ] 'have we missed?... Has heard a full set of vital therewereshortcomings in thecare provided to MrBraes at the.... News come to you '' the spokesperson said septic shock fourth visit Alex was diagnosed with a bacterial infection as! Ignored by hospital management you think one cause was you feeling under time pressure you feeling time. Triage to ask ] 'have we missed something? ' in excruciating pain and, the inquest therewereshortcomings! Hospital on 21 September, Braes was put onto the air ambulance which off. Final words after he was battling a life-threatening bacterial infection news on the BELOW CHANNELS, IBT Fast Start Let. Ignored by hospital management Braes from the Start prison are in KB 14: How did this crash! Died this remains the case. `` Edwards said it is a fictional crime scene Report of the,... From Broken Hill hospital heard the Broken Hill that rule is no longer in place Ms! It did n't prompt an investigation straight away, '' Ms Ryan said patients to Adelaide heard a full of. But the source of that infection was never confirmed, as I understandbecause an autopsy was not performed that for!, the inquest established therewereshortcomings in thecare provided to MrBraes at the hospital 7 Callum Jones Sprained! Coroners findings, '' asked Ms Edwards his overall health and age, the inquest investigating... That it did n't prompt an investigation straight away, '' asked Ms Edwards said it replayed...

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