The death of a boy whose gangrenous appendix burst, despite repeated trips to the doctor, serves as a reminder to clinicians that ignoring vital signs can be deadly, the New South Wales coroner says.

Key points: In 2017, 13-year-old Luca Thomas Raso was twice misdiagnosed with gastroenteritis, and later died from peritonitis, complicated by gangrenous appendicitis

In 2017, 13-year-old Luca Thomas Raso was twice misdiagnosed with gastroenteritis, and later died from peritonitis, complicated by gangrenous appendicitis The inquest heard no pathology tests were ordered, and the consulting GP had categorically ruled out appendicitis

The inquest heard no pathology tests were ordered, and the consulting GP had categorically ruled out appendicitis The coroner made no formal recommendations but did stress the case could be referred, to highlight the need to closely check vital signs

Luca Thomas Raso, 13, died on February 27, 2017.

An inquest into his death heard he was a cheeky, loving, popular boy who was courageous in his final days.

Coroner Teresa O'Sullivan presided over the inquest and found he had twice been misdiagnosed with gastroenteritis.

His predicament was far more dire than that, and he died from peritonitis, complicated by gangrenous appendicitis.

It came after he told his mum, Michelle Degenhardt, that his tummy hurt everywhere.

The inquest was told no pathology tests were ordered, and that the GP, Dr Pavlo (Paul) Bilokoptyov, had categorically ruled out appendicitis.

Luca died in an ambulance after a week of illness that included diarrhea and vomiting brown liquid, which his mother described as looking like "Coca Cola syrup".

Lessons to be learned

The inquest heard the 13-year-old's death was preventable and the coroner said she would refer the matter to the Royal Australian College of General Practitioners.

But Ms O'Sullivan said it was not her role to apportion blame.

"Rather than criticise Dr Bilokoptyov — who I note has been reviewed by the Medical Council NSW, with no further action taken — it is far more productive in my view to remind the medical profession that … the devil is in the detail," the coroner said.

"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."

The family had wanted the coroner to make several recommendations, including that general practitioners should be encouraged to assess and record vital signs for any patients with a provisional or differential diagnosis of gastroenteritis/appendicitis at each consultation during the period of the illness.

They also wanted her to recommend to the Bay Medical Group that it considered including in its policies manual a reminder to doctors to assess and record vital signs for patients with a differential diagnosis of gastroenteritis/appendicitis during the period of the illness.

The coroner made no formal recommendations but did stress the case could be referred, to highlight the need to closely check vital signs.

Mother wants case to be catalyst for change

Ms Degenhardt said while nothing would bring her son back, she wanted his case to change the way vital signs were checked and documented.

She fought back tears while speaking outside court.

"If the doctor had checked Luca's vital signs it would have made the difference between life and death," she said.

"I believe it should be mandatory for all children to have their vital signs taken. Kids can't explain what's happened to them, doctors need to find the time to do that.

"It's too late after somebody dies."

Ms Degenhardt said no parent should take "no" for an answer and should seek out another doctor if pain persisted or conditions worsened.

The coroner ended the inquest by reaching out to Ms Degenhardt, praising her strength and grace in the wake of the death of her much-loved boy.

Ms O'Sullivan also wanted to honour Luca's siblings and friends.

"On the final day of the hearing, Luca's family played a very moving photographic slideshow of Luca, depicting a young boy who loved life and was well-loved by all that knew him," the coroner said.

"Present in court that day were many of Luca's friends and of course his mother and siblings.

"I am grateful to them for sharing such precious memories of Luca."