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.