A review of several deaths at Bendigo Health's intensive care unit has found procedures for the determination of brain death were not always followed.
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.
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.
