Coroner's Finding: ORMEROD Madison Hayley

4y · Female·consequences of incarcerated congenital left diaphragmatic hernia

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.