‘Unacceptable’ medical delay for the death of a six-year-old boy in Broken Hill

Austin Facer’s mother remembers him as a “joyful little boy who loved life”.

NSW Deputy State Coroner Elizabeth Ryan said his family may now spend years wondering if that life could have been saved.
The six-year-old died in the early hours of October 22, 2019, after going into cardiac arrest and collapsing at his school in Broken hillin the far west of NSW, the previous day.
Austin Facer, who died while awaiting medical evacuation from Broken Hill. (The age)

School staff and paramedics were able to resuscitate him and he was taken to Broken Hill Base Hospital, where it was agreed that his condition was serious enough to require a medical transfer to a city facility.

A transfer team did not arrive until just before midnight, and Austin collapsed while being prepared for the flight, an inquest into his death found.

He was pronounced dead shortly after 2 a.m.

“The evidence established there contained significant deficiencies in the planning for the transfer, leading to unacceptable and avoidable delays,” said Ryan, who presented the findings of the inquest to Lidcombe Coroners Court on Thursday.

While everyone involved in bringing Austin back had his best interests at heart, his transfer was fraught with systemic shortcomings and flawed decision-making.

“For hours on end, there was just no set plan to take Austin anywhere.”

Facer was taken to Broken Hill Base Hospital and his condition was serious enough to require medical transfer. (Google Maps)

Ryan said she couldn’t determine if a faster transfer to a city would have prevented his death.

“But there is no doubt that a faster transfer could improve his chances of survival,” she said.

“For (his parents) there can be little comfort in this conclusion. They will always wonder if their son could have lived if his transfer hadn’t taken so long.

“The long wait that afternoon and evening must have been harrowing.”

Ryan said the inquest was important to other people living in rural and remote parts of the state, “who deserve to have access to full hospital services as soon as possible, like patients elsewhere in NSW”.

“Investigations are an opportunity to examine whether they are getting the health services they need and deserve,” she said.

“The evidence at this inquest indicated that there was a lack of clarity about which agency owned the Austin transfer, which, along with sub-optimal decision-making, led to communication and scheduling issues.”

Ryan said that while there were unacceptable delays, Austin received proper care at his school and from staff at the hospital.

She made three recommendations, including the need for mutually agreed guidelines for handovers, covering operational and clinical processes, to be arranged as soon as possible.

Six months ago, Ryan discovered “serious and unacceptable” deficiencies in the treatment of teen Alex Braes at Broken Hill Hospital.

Braes died of sepsis in 2017, after being denied entry to a tertiary facility in South Australia due to a policy that prevented interstate transfers.

At a hearing on budget estimates from NSW Health in September, it was told that Braes’ death led to an agreement with SA Health and that there were now 300 emergency transfers from Broken Hill to Adelaide each year.

Ryan acknowledged that the inquest into Austin’s death was very painful for his family.

“I know they will always grieve for Austin and I hope in time the grief will pass and they will find some peace.”

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