Mum urges doctors to remember Luca's death as inquest findings released

But the grieving mother of Luca Raso said, after the findings were handed down, that she hoped all general practitioners read about her son's case and kept him in mind when they were unsure of a diagnosis.

"Earlier this week I watched Luca's friends graduate Year 10, beginning their senior school experience," she said. "We won't ever get to see Luca do that."

State Coroner Magistrate Teresa O'Sullivan found that Luca, 13, died on the afternoon of February 27, 2017, from peritonitis resulting from ruptured gangrenous acute appendicitis following several days of serious illness.

Magistrate O'Sullivan found Luca "died as a result of a misdiagnosis of his presenting condition" during two consultations with Dr Paul Bilokopytov at a Bay Medical Group surgery in the week before his death.

She noted it led to "consequential failure therefore in receiving the appropriate referral and treatment for his appendicitis".

Dr Bilokopytov twice incorrectly diagnosed the San Clemente High School student with gastroenteritis.

The inquest in October heard that Luca died after a week of sickness that included vomiting, diarrhea, lethargy, loss of appetite and an instance of vomiting brown liquid, which his mother described as looking like "Coca Cola syrup".

Had a diagnosis of appendicitis been made, Magistrate O'Sullivan said in Friday's findings, "the majority opinion of the experts was that referral to a hospital emergency department for further examination and testing was required".

"The evidence suggests therefore that the clinical findings on examination on 22 and 24 February were consistent with a diagnosis of appendicitis or retrocaecal appendicitis," she said.

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"In fact, based on the evidence of the family and Dr Bilokopytov, appendicitis was considered as a differential diagnosis, but not eliminated by any additional investigations or referrals."

Magistrate O'Sullivan stopped short of making any formal recommendations, but said her findings would be sent to The Royal Australian College of General Practitioners.

Luca's family had asked her to consider recommending that GPs be encouraged to assess and record vital signs for any patients with a provisional or differential diagnosis of gastroenteritis or appendicitis.

But Magistrate O'Sullivan said there were already best practice guidelines in place that were almost identical to what the family had requested.

Ms Degenhardt said that if thorough vital signs had been taken, they would have told the story of what was happening to her son.

"Vital signs are so important, especially in children who can't describe their symptoms in the same way an adult can," she said.

"These vital signs would have made the difference between life and death for Luca and I believe it should be mandatory for all children to have vital signs taken [during a GP consultation]."

Magistrate O'Sullivan said rather than criticise Dr Bilokopytov - who had been reviewed by the Medical Council of NSW, which decided no further action was required - it was more productive to remind the medical profession at large 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 fatal," she said.

Outside court, Ms Degenhardt said she hoped her son would be the face of change.

"I hope that all doctors - all GPs - take the time to read it [the inquest findings] and see what happened to Luca," she said.

"However many patients a day you feel you need to see, maybe cut it back a few and just take a little more time to get a thorough record.

"I hope that doctors think about Luca when they're not sure."

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