An 11-year-old girl died after four doctors “failed to notice her appendicitis”, an inquest heard.
Lacey Brookman died after surgery to remove her swollen appendix that burst about two weeks before she was taken to hospital.
The sixth-year pupil had symptoms that were not typical of “classic” appendicitis, and accounted for only “a third of acute cases”, according to the investigation.
Four doctors at her GP practice and hospital failed to connect the dots between Lacey’s symptoms and appendicitis, and her condition was only diagnosed after an ultrasound.
Now Dr Julian Morris, senior coroner for inner south London, has published a Preventing Future Deaths Report highlighting the missed opportunities to diagnose Lacey’s appendicitis.
Dr Morris said there is a lack of “knowledge and awareness” on the issue and called for greater availability of ultrasound scans, especially out of hours.
A GoFundMe page has been set up in tribute to Lacey Brookman, describing her as someone who has a “charming smile, calm nature and a kind heart.”
Lacey, from Great Yarmouth, Norfolk, fell ill in April 2021 with abdominal pain including nausea, vomiting and constipation.
After 10 days, her mother had a telephone consultation with her GP, who determined Lacey was suffering from a virus and gave her advice on safety nets.
Three days later, Lacey’s mother received the opinion of a second GP who sent her to hospital with suspected appendicitis, after her symptoms failed to improve.
But three doctors at the hospital were unable to diagnose her condition, the inquest heard, and it was only when a consultant ordered an ultrasound that it was discovered Lacey’s appendix had burst.
The inquest found that Lacey’s appendix probably burst before her initial GP appointment.
Lacey was then transferred to a specialist pediatric unit for surgery and had her appendix successfully removed.
However, Lacey endured a “stormy post-operative period” that led to further operations and culminated in multiple organ failure.
Lacey passed away at King’s College Hospital on June 4, 2021.
Lacey Brookman, 11, passed away at King’s College Hospital on June 4, 2021 following surgery for a burst appendix.
Concluding the inquest, Dr Morris said Lacey’s condition, acute retrocecal appendicitis, was not sufficiently known.
She said in a statement: “I do not consider that there is sufficient knowledge and awareness and therefore consideration on the part of junior staff in relation to this particular type of presentation of acute appendicitis.”
‘In addition, the importance of performing an abdominal ultrasound (+/- CT) was highlighted.
“It was shown that this could only be provided by the on-call radiologist, which restricted his availability and assistance in making the diagnosis.”
The doctor added: “During the course of the investigation, testing revealed issues of concern.
‘In my opinion there is a risk of future deaths unless action is taken.
‘Neither the original GP, the reviewing surgical SHO nor the surgical registrar considered Lacey to have appendicitis. The consultant surgeon who examined Lacey on the 24th judged her to be ill but was unable to arrive at a diagnosis.
Dr Morris sent the report to the Royal College of GPs, the Royal College of Paediatricians, the Royal College of Surgeons and the Royal College of Radiologists.
The professional associations have until today to respond.
A GoFundMe page has been set up in tribute to Lacey, describing her as someone who has a “charming smile, calm nature and a kind heart.” So far it has raised more than £3,700.
