Coroner's Finding: ORMEROD Madison Hayley
Deceased
Madison Hayley Ormerod
Demographics
4y, female
Date of death
2006-09-22
Finding date
2010-09-27
Cause of death
consequences of incarcerated congenital left diaphragmatic hernia
AI-generated summary
Madison Ormerod, aged 4 years, died from incarcerated congenital left diaphragmatic hernia. Over 3 months before death, she presented with persistent vomiting and abdominal pain to her GP and paediatrician. The paediatrician focused on investigating obesity and did not adequately consider the vomiting as potentially serious, declining to order abdominal or chest imaging. When presenting to hospital in collapse, she was discharged after brief assessment without imaging or admission. Expert evidence suggested chronic vomiting warrants investigation with abdominal X-ray to exclude mechanical causes; diaphragmatic herniae are rare at age 4 but the persistent symptoms should have prompted further investigation. However, even earlier diagnosis and admission would likely not have changed the fatal outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- failure to investigate persistent vomiting with imaging
- inadequate consideration of abdominal pathology despite 3 months of vomiting symptoms
- discharge from emergency department without appropriate investigation or admission
- unusual late presentation of diaphragmatic hernia at age 4 years
- distraction by incidental finding of obesity
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