Bendigo Health has referred two deaths to the Victorian coroner after a review of the intensive care unit found procedures for the determination of brain death were not always followed.
Independent intensive care specialists found Australian and New Zealand Intensive Care Society guidelines were not followed when 11 patients were determined brain dead between June 2021 and June 2025.
While some cases were found to be administrative errors, four cases raised significant concerns and two have been referred to the Coroner's Court of Victoria.
A "small number" of the 22 cases identified by the investigators involved organ donation.
Organ donation was briefly paused at the Bendigo hospital while policies and procedures were reviewed, additional training and supervision were put in place and changes to approval processes were made.
Bendigo Health Chief Executive Officer Eileen Hannagan said while the investigators felt patient outcomes were not affected, serious concerns were raised.
"We've acknowledged with the families that what we did didn't meet the guidelines," Ms Hannagan said.
Relative felt 'hurried, pressured'
Concerns were first raised with Ms Hannagan in mid-2025, when she was told a family member felt rushed during the death of their loved one.
At that time, several staff members also raised concerns during a routine review about the death of a patient.
Ms Hannagan said the hospital "acted immediately" and engaged two senior interstate intensive care specialists who reviewed 11 cases.
They recommended a four-year review of all deaths at the hospital relating to the determination and certification of brain death.
Bendigo Health notified Safer Care Victoria and commissioned a comprehensive review by a further two independent intensive care specialists. That team reviewed four years of patient files for those who had undergone brain death testing.
The review found 11 cases where the "process didn't follow the Australian New Zealand guidelines" and the "procedures for the determination of brain death were not always followed".
Organ donation a factor in 'small' number of cases
Ms Hannagan said those 11 cases included minor administrative errors to "major concerns around the environment where that testing is appropriate, including timelines to decision making".
"There are very defined processes for brain death," Ms Hannagan said.
"They're not laws, they're recommended guidelines … and Bendigo Health's position on that is the guidelines are there for a reason so families can have confidence that decision making is based on best practice."
The guidelines set out timelines for certain steps in the process, to ensure the diagnosis is accurate and "to allow families time".
"They should be really separated, separate conversations," Ms Hannagan said.
"We can say that the timelines weren't followed and in talking to [a family] they felt hurried.
"They were clear that it didn't change the decision because they had the discussions and they knew organ donation was wanted.
"The thought other families benefited has helped them deal with the process and they appreciated our honesty and transparency."
Ms Hannagan said there was also a set of tests that should be performed and signed off independently.
"It's very clear it has to be an independent process … you can't supervise each other doing it or watch another person do it and then both sign it off," she said.
In at least one case, the independent process did not happen.
In another case, despite other testing having been completed, a family was told their loved one "could have been brain dead" before imaging was done.
Ms Hannagan said this "shouldn't have been said on the basis of a test not being fully complete".
"It wasn't to the standard any of our four reviewers felt it should be," she said.
Certain staff counselled
While Bendigo Health would not comment on individual staff, Ms Hannagan said "where appropriate, certain staff were counselled and where it wasn't appropriate it was reported".
The Australian Health Practitioner Regulation Agency, Medical Board of Australia and Safer Care Victoria have all been notified.
Ms Hannagan said while the investigators did not believe patient outcomes would have been affected and imaging was conclusive that brain activity had ceased in each case, the adopted approach did "affect how family felt about the procedure and the process".
"There are families at the centre of this. We have spoken with them directly and they have been through an incredibly difficult time and have asked that their privacy is respected."
It is believed the coroner will speak with affected family members this week.
"We are waiting to hear what the coroner's next steps are," Ms Hannagan said.
CEO thanks staff who spoke up
Bendigo Health has updated its internal policies and procedures and introduced additional safeguards, including additional senior peer support and training.
"Immediate action was to pause organ donation while we checked our processes," Ms Hannagan said.
"The checks and balances in place now won't delay the process of brain death or organ donation but they will make sure every single step of the way is progressively audited by the next one down the chain."
Ms Hannagan said the investigation had "been very difficult for our staff, who care deeply about their patients and about this community".
"I want to acknowledge the staff who raised their concerns. Speaking up when something doesn't seem right is an important part of keeping patients safe," she said.
The Victorian government released a statement saying the claims were disturbing.
"Our thoughts are with everyone affected by them and they will be supported as they deal with the news," the statement read.
"Bendigo Health has reported to AHPRA and referred the cases to the Coroner for independent consideration where they'll be seriously examined.
"Organ donation saves lives, and we are deeply grateful to donors and their families. There are strong safeguards that support organ donation across Victoria but if there's more to do, we won't hesitate to act."
Anyone with questions can phone the dedicated Bendigo Health hotline on 03 5454 8040.
