Lacey Brookman

8 Nov 2024 · Coroner Julian Morris · London Inner (South)

The coroner's concerns

1. failure to diagnose appendicitis
“Neither the original GP, the reviewing surgical SHO or surgical registrar considered that [the deceased] had appendicitis. The Consultant surgeon reviewing [the deceased] on the 24th, considered she was ill but could not reach a diagnosis.”
2. retrocaecal appendicitis overlooked
“Despite the slant of available literature, it was evident retrocaecal appendicitis presentation is not a rare presentation of either acute appendicitis or generalised abdominal pain (both common presenting features in the young)”
3. lack of ultrasound use
“The availability and use of bedside/ departmental ultrasound scanning in abdominal pain (e.g. in the young) at any time, but especially out of hours”
4. insufficient training on appendicitis differentials
“The training of doctors in considering the diagnosis as a possible differential to generalised abdominal pain”

Stated action

“We will ensure we signpost to this accordingly”