Coroner raises GP referral concerns after boy dies from missed appendicitis
The RCGP has acknowledged ‘challenges’ in information sharing between primary and secondary care following the death of an eight-year-old boy who was discharged from hospital after a GP referred him with suspected appendicitis.
The college was responding to a prevention of future deaths report into the death of Ethan Hanson, who died last year from perforated appendicitis, generalised peritonitis and sepsis.
Ethan had been referred to hospital by a GP who identified possible appendicitis ‘or another serious underlying cause’, but he was ultimately discharged from hospital after an advanced nurse practitioner mistook appendicitis for constipation.
Warwickshire area acting coroner Linda Lee had asked the RCGP to respond to concerns that ‘GPs may not be aware of the implications of referral route on triage and assessment in local hospitals’.
But some GP leaders have argued that any patient assessed by a GP as having a potentially serious illness and referred should be assessed by another doctor rather than an ANP.
The inquest into Ethan’s death established he was seen by his GP because of abdominal pain, vomiting and concern about a serious underlying cause, including appendicitis, on 23 April 2025. The GP accurately recorded a raised temperature and tachycardia.
The report said that ‘no ambulance was summoned and no written referral letter was provided’.
‘The GP advised that Ethan should go directly to hospital with his mother, apparently without appreciating that self-presentation would place him on a different pathway at George Eliot Hospital than if he had arrived by ambulance or with written referral details’, the report said.
On the GP practice’s involvement in the case, the coroner said: ‘The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations.
‘The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns.
‘There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals, and that critical deterioration indicators can be lost at the point of transfer.’
On arriving at George Eliot Hospital, Warwickshire, Ethan was triaged as ‘yellow’, which meant he saw the ANP rather than a doctor.
The report said that the GP’s concerns ‘were not available to the assessing clinician’ because Ethan and his mother had not been given a referral letter when they were sent to the hospital.
No urine dipstick or blood tests were undertaken and no clinician-assessed pain score or repeat observations were performed despite Ethan reporting severe pain, scoring 10/10.
A ‘transposition error’ then occurred in the recording of oxygen saturation and temperature which led to an incorrect temperature recording and meant Ethan was not escalated for registrar or consultant review.
A phosphate enema was given for presumed constipation. A senior medical review did not take place prior to discharge.
A consultant surgeon told the inquest that, had he reviewed Ethan, appendicitis would likely have been diagnosed, ‘though in his opinion not every clinician would have necessarily done so’.
Ethan was autistic and was awaiting an ADHD diagnostic assessment, and his mother told the inquest that she was neurodivergent, which meant that though she was ‘frightened’, she was ‘unable to articulate disagreement or challenge the decision at the time’.
Ethan was discharged from hospital and his condition deteriorated. Two days later, he collapsed and suffered cardiac arrest, and sadly died the next day, 26 April.
In its response letter, the RCGP said it was ‘not clear’ from NHS England guidance whether the threshold for referral to the emergency department applied or not.
The college said: ‘GPs are faced with a choice under time pressures given observations as recorded in Ethan’s consultation, to admit via paediatric colleagues or direct to the emergency department.
‘Secondary care pathways will differ between organisations. From a primary care perspective, it may seem that the most direct means of rapid assessment will be through ED.
‘Added awareness that primary care information and method of hospital transfer influences secondary care pathway selection needs to be highlighted to GPs if the existing secondary care pathways remain as described.’
The GP practice, Old Mill Surgery in Nuneaton, Warwickshire, said an ambulance was ‘in the process of being arranged to transfer Ethan to hospital’ but that Ethan’s mother chose to take him to the hospital ‘due to the anticipated delay’ and because the hospital was ‘approximately four minutes’ from the practice.
The practice also said at the time of Ethan’s death, ‘the practice was not aware of the specific paediatric referral pathways at the hospital, as this information had not been formally communicated to us’.
It said it had since taken steps to implement a new system to prompt clinicians at the point of referral to ‘select the correct hospital for paediatric services’; ‘access and use relevant contact numbers to notify the receiving team in advance’; ‘complete the necessary referral documentation to accompany the patient’; and ‘arrange ambulance transfer where clinically appropriate’.
Doctors’ Association (DAUK) GP spokesperson Dr Steve Taylor told Pulse the key issue in the case was that once Ethan arrived at the hospital, he was seen by an ANP rather than a doctor. He said DAUK would write to health secretary James Murray outlining its concerns around this and similar cases.
Dr Taylor said: ‘This is a very sad case and the thoughts must go to the family of Ethan.
‘The concern is that a GP had assessed and sent a patient to the emergency department but the patient wasn’t assessed by a doctor.
‘No patient who is referred into an emergency department by a GP should be assessed by anyone other than a doctor. No patient who presents with undifferentiated symptoms should be allowed home without the say so of a doctor.’
He added that it is ‘not always possible’ for GPs to refer into hospitals ‘due to issues contacting on-call doctors in a timely manner or appropriate to use an ambulance when getting children to present at emergency departments’.
A letter sent with the patient ‘could have helped’, but there was ‘no guarantee’ of that as shown by similar cases, said Dr Taylor.
‘The local referral pathways may vary across the country but if a patient has been assessed by a GP as having a potentially serious illness they should be triaged as if they have already had the initial triage and be seen by another doctor.
‘We are so concerned about this and other cases that we will be writing to the Secretary of State for Health and Social Care. Lessons must be learnt – the Ockenden Review has shown us that we can’t ignore incidents that reflect issues of patient safety.’
Meanwhile, George Eliot Hospital NHS Trust said in its response to the coroner: ‘The Trust, alongside GP and ICB representatives, acknowledged that the absence of access to GP patient records represented a significant gap in the care provided to EH.
‘Following a multidisciplinary meeting held on 29 April 2026, it was agreed that all nursing and medical staff within the Emergency Department and Clinical Assessment Unit would be granted access to the Integrated Care Record System.
‘This enables clinicians to review GP records, including the referring clinician’s working diagnosis and clinical considerations, prior to hospital assessment.’
Named respondents to prevention of future deaths reports have a statutory obligation to respond within 56 days of the report being issued.
Pulse has contacted NHS England to enquire about its response to the report.
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READERS' COMMENTS [26]
Please note, only GPs are permitted to add comments to articles
What a sad story. Whilst it wasn’t the GP who missed this diagnosis I can’t see why you wouldn’t give a referral letter – isn’t that standard clinical care?
A phone call to AED to say I am sending this patient to you and 2 minutes to write a referral letter would have been the professional approach. That should have produced a better outcome.
we referred a child with appendicitis to the local a/e dept with a letter, the child was assessed by an F2 who diagnosed gastroenteritis and discharged , the child attended another hospital 24 hours later with peritonitis.
The letter had been handed in at reception and was never seen again. I now always send a text to the patient’s phone so they can show to every hospital operative, but it cannot be taken away from them. the patient ensures the communication
Letter or no letter, surely the trust should not allow someone not qualified or experienced enough to assess undifferentiated patients to be working in a frontline role. Appendicitis is not rare. How is the ANP and trust not liable here? They had ample opportunity to redirect the patient onto the correct pathway. This looks like scapegoating of the GP.
I would give the patient an emis summary printout ant usually write my diagnosis or concerns in pen in fairly big writing on the paperwork.
Every GP’s worst nightmare now. Despite accurately identifying a sick patient the patient dies. This unfortunately is the story of acute care in the UK now. This has happened to me so many times over the last few years. 1) A&E is now meant literally for people sick enough to justify an ambulance, everyone else waits 15 hrs. 2) Same day urgent care is a single point snapshot aimed at deflection, there is no place for admission and observation to clarify uncertainty 3)multiple points of contacts for GP’s, sometimes not enough to contact Medics or Surgeons directly, you must if possible place with subspecialty directly 4) surgeons will only see pts who may need surgery in the next 48 hrs 5) different groups of staff triaging pts without senior oversight & finally, don’t forget, 6) GP’s aren’t real Dr’s – we don’t know anything. 7)The coroner has identified a good point – but missed the bigger point that it is the duty of the hospital to make info re it’s pathways available to everyone.
I will be very interested to see what records were made of the mother‘s statement to the attending triage service in the hospital. I would be extremely surprised if the words suspected appendicitis weren’t mentioned
either way it’s up to secondary care to assess and treat whatever route patients arrive by someone with expertise and certainly in the case of an ANP a Senior clinical discussion should take place before the patient is discharged
Rest of this is just Noise
Should’ve added absolutely tragic outcome probably wholly avoidable
I have had many patients sent in by personal transport or ambulance (I am old now), where there is some kind of letter, but it has not got to the hospital clinician. Following one investigation by the regulatory body for care homes for wales, after a complaint from the hospital, the letter was found on the windowsill in the A&E clinical room. Sometimes the patient has left letter in car, sometimes it has been left in ambulance (or a uniform pocket), and on one occasion I went in ambulance with patient and hospital doctor ignored and dismissed me and would not let me talk to her! We have tried sending typed letters by fax to A&E, and some of these have gone astray, or only arrived at AE later than the patient. An ANP, any hospital Receptionist, should recognise that a patient triaged by GP as needing assessment by a hospital doctor in A&E, needs to be seen by the hospital doctor, regardless of where the referral letter is. And if they cannot find it, they should contact the GP practice to ask about it – we can always send another copy! I cannot believe there were still some hospitals where clinical staff did not have access to the UHCR (GP records). However am aware many do not allow GPs access to hospital records or lab results systems!
So, the coroner is absolutely certain the parents didn’t mention once the GPs concerns? Right.
Dear coroner, a seriously unwell child arrived in a hospital emergency department and the unit not only failed to diagnose the problem by failing to examine the patient fully, but also made factual errors in recording critical examination observations which resulted in the child being sent home to die. Why does whether he had seen a GP or not make a difference to this outcome? Do all patients attend with a referal letter with clinical details? The patient was seen by a “clinician” who failed in the most basic aspects of clinical care in a department where critical illness is a frequent daily occurrence. Perhaps your focus should be on this, not looking to help the hospital mitigate its gross failings by gaslighting others.
Deflection from hospital “GP’s concerns not conveyed” is weasely and unacceptable. History from child and mother should have elicited correct pathway, and GP’s concerns. Ambulance irrelevant but referral letter would have been helpful and usual. This poor boy must have been in agony, compounded and possibly causally related to his deterioration due to being given a phosphate enema. Unless clinicians’ accountability ensues from these unforgivable errors, more deaths like these are inevitable.
Completely agree with John Mackay.
Heartbreaking story. The buck stopped with GE hospital. Coroner should be concentrating on GE’s failings regarding management by pathway and possibly cost-cutting by employing ANPs in inappropriate roles. In my 3 years as an ED Dr in the 90s, as soon as a pt entered the Dept, they were ED’s responsibility, whether they had a GP letter or not.
Why is there any reference to GP here. Nothing to do with the GP who correctly identified the probelm and sent them to a place of supposed safety. All the investgiation should start from when the patient attend A+E and what happened next. Most patients with acute abdominal pain present straight to the hospital. Why is there any GP link at all in this case ?????
How did the neurodivergent Mum get the child to the hospital?
Not a GP issue Secondary care trying to deflect the issue.
Ambulances arent taxis and if patient has transport not required Also fed up with all the questions 999 want answering not enough to say GP assessed needs urgent convance to A&E
ANP doesnt know which side the appendix is on ?
So much for Oliver Mcgowan training .
An ambulance had been called and due to the delay Mum chose to take the boy to A+E herself. the A+E is only 4 minutes away from the practice!
I’m a paediatric consultant and I think both the coroner and Dr Taylor are missing the point.
The focus on referral pathway and whether an ANP rather than a doctor reviewed Ethan is a classic “sharp end vs blunt end” problem (Reason’s safety model). Blame lands on the individuals who had direct contact with the patient. But the failure is structural.
No healthcare professional can meaningfully assess abdominal pain in a child in 15 minutes, particularly a younger child, or one with a fever. As a paediatric consultant, I would struggle to make a reliable distinction between early appendicitis and gastroenteritis in that window. The volume of children referred to hospital for ?appendicitis who turn out to have benign causes is overwhelming, and this is a predictable consequence of asking primary care to screen for surgical emergencies in appointment slots that don’t allow for it.
Sending this child without a letter, without an ambulance, but flagging him as potentially serious probably reflects entirely reasonable diagnostic uncertainty, not a failure of judgment. The problem is that without that uncertainty being formally transmitted, he became one of many undifferentiated referrals, and was assessed accordingly.
GPs need flexibility with children. The current constraints create noise down the line that is clinically unhelpful and potentially dangerous. And it’s worth saying: this child could have died the same way even with a written referral and a doctor at triage, if the underlying system problems remained unchanged.
My takeaway: if any clinician, in primary or secondary care, cannot complete an adequate assessment due to time constraints, that should be formally documented and highlighted, for every patient it applies to. That’s the only way the data exists to challenge the system rather than individual people within it.
I’m so sorry this happened, but once the child got to A&E the responsibility was with their clinicians. Secondary care don’t have access to GP records, but we don’t have access to theirs either. Bottom line – whether they saw a GP first or not – that child attended A&E and was tragically misdiagnosed. It has nothing to do with primary care. The rest of it is just noise.
Worrying times when somehow this is all the fault of GP!
No – if the ED can’t provide basic assessment and care they shouldn’t be open. The person triaging should be the most experienced person in the department, don’t blame the GP for the hospital’s incompetence.
.
Last appendicitis i saw was in a 4 year old… really struggled to get anyone to admit him-spoke to several teams- surgical/paeds -local hospital surg reg wouldn’t accept and said you dont get appendicitis in under 5s. Ended up getting him into paeds surgery in neighbouring county hospital- it was appendicitis and he did ok but took me 2 hours of phoning round. That was probably 10 years ago- couldn’t even get as far as speaking to a dr now- would be SAU with letter and 14 hr wait !
Anyone else struggling to understand how a 8 year old boy can be prescribed a phosphate enema but nothing else be done?
How, given appendicitis is pretty much the number one thing to consider in any child with abdo pain, that given reported pain levels of 10/10 this child was discharged after no bloods, no urine dip and what seems to be no correctly repeated or documented obs on a chart and thus I make the assumption the clinician who examined the patient did not feel the tummy or do their own observations when examining.
We therefore have a clinician or a team that have done none of the above but yet are competent enough to prescribe a phosphate enema to a 8 year old and discharge the child. I find that frightening. Cant find the answer as to whether this enema was administered in hospital. Either way the poor child has had to go through that.
For all the discussions around systems, letters , ambulance availability this boy was failed by the hospital. He got sent there, was seen and was sent away.
So the coroner’s message is all in the media further exacerbating the GP-is-to-blame narrative. So our representatives (BMA) should be full out in the media to counteract and place a reality check on the Coroners comments- right?! Come on BMA…stand up for GPs!!!
Further to Jim Lawrie’s contribution ( 30th June ) I think sending a message to the patient’s / carers phone is an excellent failsafe / add on measure . I recently referred a middle aged lady with headaches whose optician felt she might have papilliedema ( expressed in a letter to me ) to the Eye Casualty – my referral letter was handed in to an administrator there and not seen by the Duty Ophthalmologist, who made no reference about this concern to the patient nor in any return correspondence.
You can’t win but
1 Wait for the ambulance
2 Provide a letter clearly expressing your concerns
3 Send a text to patient/parent; this is a new one (Thanks Jim Lawrie)