In the small hours of a Wednesday in an outback town, a teenager struggled to sleep.

Eighteen-year-old Alex Braes' knee was so painful, he asked his father to take him to Broken Hill Hospital.

The timeline of what happened next is a harrowing account of failure in Australia's regional hospitals, where resources are stretched and staff are under constant pressure.

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.

According to these figures, for every 100,000 people, there are 91.6 avoidable deaths in major cities, compared to 248.7 avoidable deaths in very remote parts of the country.

These figures meant the odds were against Alex Braes from the start. But so shocking is his case that it's prompted a group of clinicians who worked at Broken Hill Hospital to blow the whistle on what they believe is a hospital that had dangerous, systemic failures for years.

Before Alex's death, doctors had complained repeatedly that management was not open to criticism and did not listen to safety concerns they raised.

Wednesday, September 20, 2017, 3.18am

Alex arrived at Broken Hill Hospital's emergency department.

Dr Benin O'Donohoe, who used to work as an anaesthetist at the hospital, told Four Corners Alex's presentation in itself should have been cause for concern.

Eighteen-year-old Alex Braes. ( Supplied )

"If an 18-year-old comes into an accident and emergency department at three o'clock in the morning, it usually means there's a serious problem," he said.

Instead, medical staff in the emergency department made the assumption Alex had a sporting injury.

Crucially, no-one did vital-signs observations such as check Alex's pulse, blood pressure, or temperature and they didn't take any blood for testing.

Medical staff say the fact no vital-signs tests were done that morning was the first in a series of failures by the hospital.

Alex was told to go home and come back later that morning for an ultrasound.

Wednesday, 8.00am

Alex and his father arrived back at the emergency department.

After his ultrasound, he expected a doctor to review his results but the emergency department was so busy, no-one could see him.

Broken Hill hadn't been able to get a GP that week to staff the fast-track clinic which saw less-serious patients, so that put enormous pressure on the emergency department.

Again, no-one checked Alex's vital signs.

Alex and his father were told to go home and come back later.

Wednesday, 6.00pm

Alex presented to Broken Hill's emergency department four times. ( ABC News )

Alex and his father arrived back at the hospital.

Max McLean was the after-hours nurse manager at Broken Hill.

Mr McLean says by this stage — Alex's third presentation — alarm bells should have been ringing.

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"Certainly other hospitals will highlight a second presentation or third presentation, [to ask] 'have we missed something?'" Mr McLean said.

Broken Hill staff had missed something, but still, no-one did proper observations of Alex.

Former Broken Hill obstetrician Dr Simon Stewart-Rattray told Four Corners the failure to do vital-signs observations was "indefensible".

"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.

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.

By the following morning, Alex's pain was so excruciating, he couldn't walk. He called his father home from work.

Thursday, 10.00am

Alex's father called triple zero to ask an ambulance to take his son to hospital, but no ambulance was available.

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.

When they arrived, Alex was unable to get out of the car, so his father went to triage to ask for help. It took 25 minutes for a wheelchair to be brought out so Alex could be taken from the car into the hospital.

Dr Stewart-Rattray says he and other clinicians who worked at Broken Hill had warned about mismanagement and a lack of resources that posed a risk to patient safety.

"I've worked in 13 different locum hospitals since I've retired and I've never seen anything like Broken Hill in my entire career," he said.

Broken Hill, in far western New South Wales, is more than 1,100 kilometres from Sydney. ( Four Corners )

Thursday, 11.39am

Alex's father wheeled him into the emergency department and a nurse observed him through a window and asked him to wait.

Dr Kerrie MacDonald is a paediatrician who used to work at Broken Hill Hospital and is still in the NSW health system.

She told Four Corners that by this stage, Alex was desperately unwell, yet he was again left waiting.

"He complained that he might pass out or faint, so his father asked for a pillow," she said.

The nurse did not provide the pillow but left her post to go out into the waiting room to check on Alex. She noticed he was sweaty and unwell and moved him into a bed in the emergency department.

Thursday, 12.17pm

Thirty-three hours after he had first presented to Broken Hill Hospital, hospital staff finally did vital-signs observations.

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.

It's something that troubles local MP Roy Butler.

"What are we doing about avoidable deaths, preventable deaths?" the NSW member for Barwon said.

"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."

Thursday, 12.28pm

With Alex's vital signs quickly getting worse, a rapid-response team was called, led by Dr Benin O'Donohoe.

By then, Alex needed resuscitation.

"Alex was semi-conscious, he was rambling, he wasn't responding to simple questions," Dr O'Donohoe said.

"He was cold, clammy, sweaty and he was significantly blue and mottled and this mottling colour is really a very ominous feature.

"It means he'd been unwell for a significant number of hours at that point."

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.

Alex was now in toxic shock from a deadly, flesh-eating disease known as necrotising fasciitis.

"The kidneys start to fail in what is an overwhelming sepsis and that is something that we were battling against, because we didn't actually have the resources to support failing kidneys — that's why we needed to get him out," nurse Max McLean said.

Dr Benin O'Donohoe would eventually resign from Broken Hill Hospital. ( Four Corners )

Dr MacDonald believes if you're in a remote centre and become gravely ill, the hospital needs to be equipped for what she describes as a "grab and go".

"You need to move that patient as soon as you possibly can to an organisation that has the facilities, the staff to manage the patient as best as possible," she said.

There was no "grab and go" for Alex and that would have devastating consequences.

Thursday, 1.25pm

Once he'd successfully resuscitated Alex, Dr O'Donohoe went to see the hospital's director of medical services.

"[I] informed him that we had the sickest patient I'd seen since my time in Broken Hill," he said.

Thursday, 1.47pm

The nearest tertiary hospital to Broken Hill was Royal Adelaide, which although in another state, had a much closer flying time than Sydney.

Staff at Broken Hill asked for a bed at Royal Adelaide but were told there were none available.

Thursday, 2.05pm

Dr O'Donohoe spoke to the Royal Flying Doctor Service at Broken Hill.

"[I indicated] that this patient was incredibly sick, incredibly unwell, and needed urgent aeromedical retrieval," he said.

But the Flying Doctors were unable to transport Alex because the only available pilot had already reached their maximum flying hours — a regulation governed by the Civil Aviation Safety Authority.

Thursday, 2.32pm

It would take at least five hours for Alex to be collected by an air ambulance and taken to Sydney's RPA. ( ABC South East SA: Kate Hill )

Staff managed to find a bed for Alex at Sydney's Royal Prince Alfred Hospital and an air ambulance left Sydney to come and collect him.

It would be a five-hour round trip.

"His parents were just shell-shocked. They sat there. I just think they were trying to grasp the reality of what was facing them and that he was deteriorating very quickly," Mr McLean said.

Thursday 5.30pm

Alex's mother was sent to wait at Broken Hill airport while his father went home to pack a suitcase. He would follow them to Sydney on a commercial flight.

But their boy suddenly deteriorated sharply.

Mr McLean says staff had to provide life support before Alex could be put on the plane.

"We had to intubate him so that we could actually keep him stabilised on the flight," he said.

Alex's mother was left standing outside near the airport tarmac for hours as Alex, still back at the hospital, fought for his life.

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Thursday, 9.30pm

Alex finally left the hospital and was put onto the air ambulance which took off with his mother also on board.

During the flight Alex continued to decline and, as his mother watched, the paramedics struggled to keep him stable, having to phone doctors for advice.

"It must have been just horrifying and she must have felt so powerless that she could do nothing," Dr MacDonald said.

"She must have hoped beyond hope that he would survive."

Alex Braes. ( 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.

It was far too late. He went into cardiac arrest.

Friday, 2.00am

Eighteen-year-old Alex Braes was pronounced dead.

'We failed him'

Alex's parents were too distressed to be interviewed, but conveyed to Four Corners the loss of their son had left them feeling that, to the hospital system, he was worth nothing.

His death has also devastated the clinicians working at Broken Hill.

"A young man who died, essentially, from an infected toenail, from the consequences of an untreated and very common infection. I think it was a totally avoidable death," Dr MacDonald said.

"All I can say is since I became aware of the death of Alex Braes, I don't think I have stopped thinking about that young man."

Dr O'Donohoe later quit work at Broken Hill Hospital over what he saw as mismanagement, leading to patient safety issues.

He believes Alex's death was a consequence of poor structure and organisation at the hospital.

"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.

The failures did not end there.

Delays in investigation

Dr Kerrie MacDonald says Alex Braes' death was totally avoidable. ( Four Corners )

Broken Hill Hospital management downgraded the categorisation of Alex's death, meaning it wasn't referred immediately for an investigation, as is required under the state's Health Administration Act.

It would eventually take a whole year for an investigation to be done — and that only happened because the doctors repeatedly lobbied the Ministry of Health and, ultimately, wrote to NSW Health Minister Brad Hazzard, to intervene.

Mr McLean says he spoke up and tried to get something done but he was ignored by hospital management.

"I was gobsmacked that it didn't prompt an investigation straight away," he said.

Dr MacDonald believes the law was being breached.

'I think of that boy frequently'

In an interview with Four Corners, Mr Hazzard said he was "not sure" the hospital broke the law, but Alex's death was a circumstance that, "as a father, I couldn't have imagined happening".

"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.

"And my greatest sympathy and sorrow, actually, to his family. It was a horrific outcome and such a young man, only 18 years old."

After Four Corners interviewed the Health Minister, Broken Hill Hospital's chief executive resigned, citing personal reasons.

But questions are expected to continue about the handling of Alex Braes' case.

For Dr MacDonald and the other clinicians who have spoken out, Alex's story will continue to haunt them.

"I didn't know his family, I didn't know Alex Braes. I don't even know what he looks like. But I can say to you that I think of that boy frequently," she said.

"And I think that the clinicians who would have been with him when he was so sick in emergency will not forget him."