Inquest into the death of Luca RASO
Deceased
Luca Thomas Raso
Demographics
13y, male
Date of death
2017-02-27
Finding date
2019-12-13
Cause of death
Peritonitis secondary to ruptured gangrenous acute appendicitis
AI-generated summary
Luca Raso, a healthy 13-year-old boy, died from peritonitis secondary to ruptured gangrenous acute appendicitis after being misdiagnosed with viral gastroenteritis by his GP on two consultations (22 and 24 February 2017). He presented with vomiting, diarrhoea, and generalised abdominal pain, but the GP failed to consider appendicitis as a differential diagnosis requiring investigation or referral. Critical failures included: inadequate history-taking (not documenting pain severity or functional impact), incomplete examination (cursory vital signs, no pulse recorded, no stethoscope used), failure to investigate despite deterioration over several days, and failure to refer when symptoms persisted. Expert evidence showed normal bowel sounds with vomiting history is uncommon, appendicitis can present atypically with retrocaecal location, and blood tests plus imaging would have revealed bacterial rather than viral illness. The case highlights the importance of detailed history, thorough examination, recording vital signs, and considering differential diagnoses even when presentations seem benign.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Misdiagnosis of viral gastroenteritis instead of appendicitis
- Failure to take detailed history of symptoms including pain severity and functional impact
- Incomplete physical examination with inadequate assessment of vital signs
- Failure to record pulse at either consultation
- Failure to adequately examine abdomen or use stethoscope properly
- Failure to consider or eliminate appendicitis as differential diagnosis
- Failure to order appropriate investigations (blood tests, imaging) despite clinical deterioration
- Failure to refer to emergency department despite non-improving symptoms over multiple days
- Atypical presentation of retrocaecal appendicitis contributing to diagnostic difficulty
- Failure to follow up adequately on concerning telephone communication from mother on 23 February
- Receptionist failure to escalate care despite triage guide recommendations
Coroner's recommendations
- Provide findings to the Royal Australian College of General Practitioners (RACGP) with invitation to publish a case note in the Australian Journal of General Practice
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