NSW Coroner finds teen was misdiagnosed by GP twice before he died in 2017 of appendicitis

13 December 2019
The NSW State Coroner has found a doctor twice misdiagnosed a teenage boy’s appendicitis as a gastro virus before the 13-year-old collapsed and died.

Handing down her findings in Newcastle today into the death of Port Stephens teen Luca Thomas Raso, Teresa O’Sullivan said the doctor’s misdiagnosis meant Luca did not receive the appropriate referral and treatment.

Luca died on February 27, 2017, five days after his first visit to the Nelson Bay Medical Group surgery. Dr Paul Bilokopytov diagnosed him with viral gastroenteritis.

Luca returned to see the doctor on February 24 complaining of severe diarrhoea, loss of appetite, lethargy and problems walking, but again the GP diagnosed him with gastro and did not order pathology tests.

Three days later Luca collapsed on the bathroom floor of his home and later died at Tomaree hospital.

An autopsy found the cause of death had been peritonitis secondary to a ruptured gangrenous appendicitis.

The Coroner said she would send her findings to the Royal Australian College of General Practitioners so lessons can be learned from Luca’s death.

She said rather than criticising Dr Bilokopytov for his management of some aspects of Luca’s presentation, “It is far more productive in my view to remind the medical profession that ... ‘the devil is in the detail’.

“To search for the details requires probing and scrutinising the patient’s presenting history and conducting a thorough and complete examination to establish the provisional diagnosis but includes eliminating the differential diagnosis, in particular when the differential diagnosis if left untreated can present as a medical emergency and (be) fatal,” she said.

Dimitra Dubrow, Maurice Blackburn Lawyers’ national head of medical negligence, said while the Coroner did not make specific recommendations for guidelines to be developed to GPs in relation to taking patients’ vital signs, “this is a very strong finding about the need for there to be thorough investigations and for a detailed history to be taken in consultations, especially when a sick child presents and represents.

“The Coroner has highlighted the requirements that already exist in regulations for doctors to take detailed notes in relation to diagnosis, examinations and tests, and said this case acted as a powerful reminder about the standards expected to be followed by all GPs, which provide a safeguard to minimise risks in diagnosis, treatment and management of patients,” Ms Dubrow said.

“We are pleased that the findings will be distributed to Royal Australian College of General Practitioners so that all GPs will be made aware of the need for thorough investigations, comprehensive record keeping and referral to hospital when a sick child like Luca presents.”

Luca’s mother, Michelle Degenhardt, who campaigned for the inquest to examine the circumstances leading up to his death, said that if the doctor had checked Luca’s vital signs, her son might still be alive today.

“I believe it should be mandatory for all children to have their vital signs taken... when they go to see a GP,” Ms Degenhardt said outside court.

“Kids can’t explain what has happened to them. Doctors need to find the time to do that. It’s too late after somebody dies.”

She warned all parents to “trust you gut” whenever they believed their children were seriously ill and demand that doctors checked their vital signs.

Ms Degenhardt is pursuing a civil compensation claim against Luca’s treating doctor.

Media inquiries:  Andrea Petrie at Maurice Blackburn Lawyers on 0412 655 264

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