Leo Barraclough, 86, walked into the emergency department at Caboolture Hospital one afternoon in June 2024 complaining of severe back pain. Twenty-one hours later he was dead, and a confidential internal review has since identified a series of failures in his care, including critical delays in assessment, monitoring and treatment. His family is demanding answers about why the hospital recorded the death as 'not unexpected' and initially did not refer it to the coroner.
Leo Barraclough, a pensioner from the town's north, arrived at Caboolture Hospital in June 2024 seeking treatment for chronic back pain. A slow-acting blood cancer, Myelodysplastic Syndromes (MDS), had weakened his immune system, but the condition was not expected to cause his sudden death.
According to patient records and a review by Metro North Health Service, the first failures emerged within 45 minutes of triage. Mr Barraclough was given Ibuprofen and Endone for his pain, but his vital signs were not recorded. The review noted that Ibuprofen should be used with caution in patients with asthma; Mr Barraclough was an asthmatic.
Over the next 12 hours, clinicians missed multiple opportunities to intervene. Observations were incomplete or not taken, a sepsis pathway was never signed off by a senior nurse, and antibiotic treatment was delayed for nearly 12 hours after arrival. At one point Mr Barraclough's oxygen levels dropped to around 80 percent, while healthy levels are above 95.
The review flagged as a 'missed opportunity' that no sedation score was recorded after opioid medication was administered, and that a deterioration score was not documented when his condition worsened. A Queensland Health clinician who reviewed his charts told the ABC that opioids are known to slow breathing and that a patient in his condition needed very close monitoring.
Mr Barraclough's wife left the hospital thinking he would recover, only to be told later that day that he had died. The hospital told the family the cause was Neutropenia and pneumonia, and recorded the death as 'not unexpected'. The family was horrified. 'There were so many things that didn't add up,' said his daughter, Kym Vassiliou.
The ABC reports that the coroner's office advises that a death is reportable if health care caused or contributed to the death and the outcome was unexpected. The hospital initially decided not to refer the case. After the ABC sent questions about his care, Metro North said it had referred the death to the coroner 'out of an abundance of caution'. The service offered condolences and said improvements around documentation had been implemented and an open disclosure meeting held with the family. 'He would hate that this hospital would get away with what they did and that more people might come into the same situation,' Ms Vassiliou said.
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Analysis
Why This Matters
The case raises concerns about how hospitals determine whether a death should be reported to the coroner, a process that can trigger independent investigation and system-wide reforms.
Delayed treatment and missed monitoring steps are recurring issues in busy emergency departments, and the review's findings point to staffing pressures and unclear standards of observation.
If similar deaths are routinely categorised as 'not unexpected', preventable errors may remain hidden.
Background
Caboolture Hospital is a state-run public hospital north of Brisbane, part of the Metro North Health Service. Its emergency department has struggled with high demand and staff shortages. The hospital had recorded a 'missed opportunity' for Mr Barraclough's care, and the review identified no 'minimum standard' for how often observations should be taken in his circumstances.
What to Watch
Whether Queensland Health orders an independent external investigation into the death, as the family has requested.
Whether the criteria for reporting deaths to the coroner are tightened, so that cases involving potential health-care failure are automatically reviewed.
Any changes to Caboolture Hospital's procedures for monitoring patients with chronic conditions who present with acute pain.
12 claims in this story checked against 1 source: 10 supported.
Show each claim
SupportedVassiliou said, “There were so many things that didn't add up.”Just In: “"There were so many things that didn't add up," Mr Barraclough's daughter Kym Vassiliou said.”
SupportedBarraclough, 86, died 21 hours after walking into hospital for back-pain treatment.Just In: “He walked into hospital for back pain treatment. He was dead 21 hours later.”
SupportedA hospital review flagged multiple care failures.Just In: “An ABC investigation found there had been multiple problems with the care provided to Mr Barraclough before he fell into an unconscious state from which he never woke.”
SupportedThe family considered Barraclough's death unexpected, while the review identified missed opportunities.Just In: “The family were horrified. The death was anything but "not unexpected" for them.”
SupportedThe hospital recorded the death as “not unexpected” and initially did not refer it to the coroner.Just In: “One confirmed the case did not need to be reported to the coroner who is supposed to be informed if a patient death is caused by bad health care. The other described the death as "not unexpected".”
Partly supportedBarraclough's MDS was not expected to cause his sudden death.Just In: “The condition was not expected to cause his sudden death, according to his family.”
SupportedWithin 45 minutes of triage, Barraclough received ibuprofen and Endone, but his vital signs had not been recorded; the review noted ibuprofen should be used with caution in patients with asthma.Just In: “Within 45 minutes of Mr Barraclough being triaged as a non-urgent patient, he was given Ibruprofen and some Endone for his back pain, according to patient notes. The confidential review ... found Mr Barraclough's vital signs had not been recorded despite the fact Ibuprofen "should be used with caution in patients with asthma".”
SupportedThe sepsis pathway was not signed off by a senior nurse, and antibiotics were delayed for nearly 12 hours after arrival.Just In: “this program, called a Sepsis Pathway, was never signed off by a senior nurse, the review revealed. He did not receive antibiotics until many hours later.”
SupportedBarraclough's oxygen levels fell to around 80 per cent, while healthy levels are above 95 per cent.Just In: “His oxygen levels were now around the 80 per cent mark, according to notes. Healthy levels are above 95 per cent.”
SupportedA Queensland Health clinician told the ABC that opioids are known to slow breathing and a patient in Barraclough's condition needed very close monitoring.Just In: “"Opioids are known to slow breathing. A patient in his condition would need to have been very closely monitored in this situation," the clinician said.”
Partly supportedThe ABC says the coroner's advice makes a death reportable if health care caused or contributed to it and the outcome was unexpected.Just In: “The coroner's office's official advice said a death is reportable if the health care caused or contributed to the death or a failure to provide health care caused or contributed to the death. "And the death was an unexpected outcome of the health care being provided," it said.”
SupportedAfter the ABC sent questions, Metro North said it referred the death to the coroner “out of an abundance of caution.”Just In: “Four days later, Metro North said that his death had been referred to the coroner "out of an abundance of caution".”
Correction
An earlier version of this story said the family regarded the death as not unexpected. The family regarded it as unexpected. It also altered the wording of a quote from Kym Vassiliou; her exact words have been restored. The story omitted Metro North's subsequent referral of the death to the coroner and incorrectly stated that no independent investigation had been conducted. It also attributed advice about closer monitoring to the internal review rather than a Queensland Health clinician who reviewed the patient charts.