Broken Hill teenager Alex Braes' parents remember him as a ray of sunshine, a funny and smart young man ready to live a full life.
But the 18-year-old mechanic died with "tragic suddenness" in the early hours of September 22, 2017, suffering multi organ failure due to sepsis, one month after treatment for an infected ingrown toenail.
NSW deputy state coroner Elizabeth Ryan on Monday handed down her findings into Mr Braes' death, saying there was a serious and unacceptable deficiency in his treatment at Broken Hill Base Hospital.
Ms Ryan also outlined major delays in transferring Mr Braes to the Sydney hospital where he died, after he was refused admission at a South Australian tertiary facility due to a policy preventing interstate transfers.
She recommended NSW and SA health departments urgently agree to cross-border transfers of critically ill patients from Broken Hill.
The inquest heard hospital staff did not check Mr Braes' full vital signs, including temperature, pulse and blood pressure, when he presented to the emergency department with severe leg pain on the morning of September 20.
This was due to a "business rule", which discouraged staff from taking vitals during the triage stage in order to improve efficiency.
Witnesses told the inquest the rule had limited oversight from senior management and staff generally disapproved of it.
Ms Ryan found it was potentially dangerous and against NSW Health policy, but a systemic failure that could not be attributed to individual hospital staff.
"I have found the failure to perform vital signs observations was a serious deficiency in the care provided to Alex," Ms Ryan said in her findings.
The inquest also heard Broken Hill Hospital is prevented from transferring patients to Adelaide facilities despite the SA capital being closer than Sydney.
Ms Ryan recommended the communication between NSW and SA be escalated to the NSW secretary of health if cross-border transfer arrangements are not in place within a year.
The delayed transfer also deprived his parents of seeing him in his final hours, as they left the hospital to prepare to travel with him.
"It grieves his parents deeply that they were not able to be with him in his last conscious hours," Ms Ryan said.
Mr Braes had taken antibiotics for an ingrown toenail a month before his death, though investigating doctors told the inquest they could not be sure it was the cause of the later infection in his leg.
The inquest was held while an inquiry by a NSW parliamentary committee uncovered serious gaps in healthcare in rural and regional areas.
It recently handed down 44 recommendations to boost the rural medical workforce and improve the standard of care.
"I hope the recommendations made by the committee are taken to heart and the health needs of Broken Hill patients will be better met in the future," Ms Ryan said.
