Inquest into the death of Luca RASO

13y · Male·Peritonitis secondary to ruptured gangrenous acute appendicitis

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.