A NSW mother of a 13-year-old boy who collapsed and died after his appendicitis was twice misdiagnosed as a gastro virus says doctors need to lift their game.
"Don't just take your doctor's word as gospel because those days are gone," Michelle Degenhardt said on Friday. "We can't do that anymore."
Ms Degenhardt was speaking outside a Newcastle court after coroner Teresa O'Sullivan found the misdiagnosis meant Port Stephens teenager Luca Raso didn't receive appropriate treatment before he died.
Luca died in February 2017 after being ill for a week. He'd been vomiting and had severe diarrhoea, appetite loss, lethargy and problems walking.
He collapsed on the bathroom floor and died later at Tomaree local hospital.
An autopsy found the cause of death had been peritonitis secondary to a ruptured gangrenous appendicitis.
Luca was examined twice by Dr Paul Bilokopytov at the Nelson Bay Medical Group surgery in the week before he died and diagnosed as suffering from viral gastroenteritis. The GP did not order pathology tests.
"Rather than criticise Dr Bilokopytov ... for his management of some aspects of Luca's presentation, 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."
Ms O'Sullivan noted Dr Bilokopytov had been reviewed by the Medical Council of NSW with no further action taken.
The coroner praised Ms Degenhardt - who campaigned for the inquest - as a "strong and gracious advocate" for her beloved younger son.
Ms Degenhardt said if Luca's blood pressure had been taken at the time, it would have shown his body was in freefall.
"I didn't know I had to be medically literate to be able to advocate for my child," she said outside court.
Ms Degenhardt said she was constantly being reassured Luca was OK and he just had gastro.
She believes it should be mandatory for doctors to check a patient's vital signs. That would have made the difference between life and death for Luca.
"It just should never have happened," she said.
"I hope doctors think about Luca when they're not sure (about a diagnosis).
"However many patients a day you feel you need to see, maybe cut it back a few, and just take a little bit more time to get a thorough (medical) record."
Lawyer Dimitra Dubrow said the case was "a powerful reminder about the standards expected to be followed by all GPs which provide a safeguard to minimise risks in diagnosis, treatment and management of patients".
Ms Degenhardt and Luca's sister, Victoria, claimed the doctor was told the teenager had repeatedly complained about abdominal pain.
But Dr Bilokopytov denied ever being told Luca had abdominal pain or that he complained "it hurts everywhere".
The doctor was shocked to hear of Luca's death as he did not believe the boy had been in pain which was why he ruled out appendicitis.
Australian Associated Press