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”.

Alex Braes, 18, died on 22 September 2017 from multi-organ failure due to sepsis from a Group A streptococcus infection.

His death, which the coroner said could not “realistically” have been prevented, came two days after he first presented to the 80-bed Broken Hill Base Hospital with severe left knee pain.

On 20 September, at the first of his three presentations in 24 hours, the senior registrar recorded that his knee was swollen and “felt hot” but that there was no redness.