# Bendigo Health Review Finds Failures in Brain Death Procedures Hospital admits to procedural lapses in brain death certification and organ donation protocols. - **Source:** [ABC Australia – Just In](https://www.abc.net.au/news/justin) - **Published:** 2026-11-10 - **Topic:** [health](https://brifing.si/c/health) - **Original article:** - **On Brifing:** https://brifing.si/s/5403525f-ce60-4529-9c55-5ba94acaf3e0 ## Procedural Lapses Identified An investigation into Bendigo Health’s intensive care unit revealed that brain death determination protocols were not consistently followed. Independent specialists reviewed 22 cases from June 2021 to June 2025, identifying 11 instances where established clinical guidelines were breached. These failures ranged from minor administrative errors to significant concerns regarding testing environments. ## Coroner Referrals Initiated Following the comprehensive review, four cases were flagged for raising significant concerns regarding patient care standards. Consequently, Bendigo Health has referred two of these cases to the Coroner’s Court of Victoria for further independent examination. The hospital is currently awaiting guidance from the coroner regarding the next steps for these investigations. ## Organ Donation Pause Bendigo Health temporarily suspended organ donation services while conducting an internal audit of its policies and procedures. This pause allowed the facility to implement additional training, supervision, and updated approval processes. The hospital aimed to ensure that all future procedures align strictly with the Australian and New Zealand Intensive Care Society guidelines. ## Independent Verification Failures The review highlighted critical issues with the independence of testing procedures. In at least one instance, the required independent sign-off process was not performed correctly. Furthermore, some families reported feeling rushed during the sensitive process of brain death certification, which contradicts the recommended best practices for communication and family support. ## Communication and Ethics Guidelines mandate that discussions regarding the futility of care should be strictly separated from organ donation conversations. Investigators found that these distinct discussions were sometimes conflated, causing distress to families. CEO Eileen Hannagan acknowledged that while clinical outcomes remained unchanged, the hospital’s failure to follow these communication standards was unacceptable. ## Staff and Regulatory Response The hospital notified the Australian Health Practitioner Regulation Agency and the Medical Board of Australia about the findings. While Bendigo Health declined to comment on individual staff members, management confirmed that appropriate counseling was provided. The hospital leadership publicly thanked the staff members who initially raised concerns, emphasizing the importance of transparency. ## Systemic Safeguard Updates To prevent future lapses, Bendigo Health has introduced new safeguards, including mandatory senior peer support and progressive auditing of every step in the certification process. These measures are designed to ensure that clinical decisions are based on best practice, providing families with the confidence that the diagnosis is accurate and handled ethically. ## Broader Healthcare Implications The Victorian government described the findings as disturbing and pledged support for all affected families. This incident underscores the necessity of strict adherence to national guidelines in high-stakes medical environments. By referring cases to the coroner, the hospital seeks to ensure full accountability and maintain public trust in the organ donation system. ## Sources covering this story - https://www.abc.net.au/news/2026-11-11/bendigo-hospital-brain-deaths-organ-donation-families-rushed/107371332 — --- _Summary written by Brifing from the original reporting. Copyright in the original article belongs to its publisher; read the full piece at the link above._