Finding into death of HM

15y · Male·Gastric perforation with early peritonitis; Acute gastric distension and chronic gastritis

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.