Finding into death of HM
Deceased
HM
Demographics
15y, male
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2015-12-10
Finding date
2021-06-29
Cause of death
Gastric perforation with early peritonitis; Acute gastric distension and chronic gastritis
AI-generated summary
HM, a 15-year-old boy with suspected autism spectrum disorder and depression, died from spontaneous gastric perforation with early peritonitis secondary to acute gastric distension. He had dysfunctional eating patterns, poor school attendance, social isolation, and refused medical follow-up. HM did not communicate symptoms to parents; acute illness was only recognized when his father found him vomiting. While the gastric perforation itself was unpredictable and unpreventable, the case highlights systemic barriers to ASD diagnosis and mental health support in adolescents. Key lessons: early recognition and diagnosis of neurodevelopmental conditions is essential; multidisciplinary assessment requires accessible pathways; schools and health services must coordinate effectively; and families need adequate support accessing diagnostic services. The coroner noted multiple system barriers prevented timely ASD assessment and appropriate mental health intervention.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Dysfunctional eating patterns with poor appetite and limited food intake
- Possible decreased gastric motility or gastric muscle atrophy
- Undiagnosed autism spectrum disorder
- Depression and mental health decline
- Social isolation and school refusal
- Poor communication of symptoms to parents
- Delayed recognition of acute illness due to poor mental health
- Limited access to specialist mental health and diagnostic services
- Barriers to accessing ASD assessment including cost and wait times
Coroner's recommendations
- The coroner endorsed the Victorian Autism Plan as providing a considered approach to reducing barriers to assessment and appropriate education and support for people with autism spectrum disorder
- Schools should have clear pathways in place, including working with parents, to enable timely access to specialist assessment not prevented by lack of funding
- Need for systems improvements to address barriers across multiple sectors for children to access appropriate diagnostic services and families to access appropriate support services
Full text
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.